In 2009, the NHS’s Gender Identity Development Service (Guide) saw fewer than 50 children per year. Since then, demand has increased 100-fold, with more than 5,000 seeking help in 2021-2022.
In her overview of gender services, Dr Hilary Cass said there had been a ‘dramatic increase’ in presentations to gender clinics over the past decade, particularly by women registered at birth. In 2009, Gids treated 15 girls. By 2016, that number had risen to 1,071.
“There has been a significant change in the population of young people over the last 10 to 15 years,” Cass told BBC Radio 4’s Today program on Wednesday.
“So about 15 years ago the service was seeing perhaps 50 predominantly birth-registered boys in childhood. And over the last decade it has moved on to more than 3,000 young people, and it’s mainly birth-registered girls presenting in their early teens…often with quite complex co-morbidities.”
There is no single explanation for the increase in the prevalence of gender incongruence or the specific increase in the number of registered births to which Gids refers, her research concluded.
But it says several factors may explain the increase in predominantly birth-registered women presenting to gender services in early adolescence:
Generation Z and Generation Alpha (born since 2010) have grown up with “unprecedented” online lives, the report said. This has great benefits, but also brings risks and challenges.
Greater access to the internet has given children and young people learning tools “but it has also made them vulnerable to new dangers,” the review said.
“The biology hasn’t changed and the biology of adults hasn’t changed in recent years,” Cass told the Guardian this week. ‘So it’s not like that has changed things.
“I don’t think young people today are exposed to more abuse, trauma or anything like that than previous generations. We need to think very seriously about the impact of social media.”
According to the report, girls spend more hours using social media than boys. A study cited by Cass found that 43% of girls use social media three or more hours a day, compared to 22% of boys.
A systematic review that highlighted the Cass report found that social media use was linked to body image concerns. Numerous other studies cited in the report imply that smartphone and social media use leads to mental health problems and suicidality among young people, especially girls.
They all showed a clear dose-response relationship: the more hours spent online, the greater the effect.
Peer and sociocultural influence
The report suggests that while the impact of societal influences on a child’s gender expression remains unclear, it is clear that the influences of a child’s peers are “very powerful during adolescence.”
Although the report does not specifically state that girls are more affected than boys by social and cultural influences such as peer pressure, including their gender expression, other evidence has suggested that this is the case.
Several studies have suggested that girls suffer more from peer pressure than boys, and that they are at greater risk of developing negative body image during adolescence.
Another societal influence referenced in the report as potentially affecting young people’s gender expression includes information about gender dysmorphia and gender expression found online.
More specifically, a focus group of young people and their gender-questioning parents who spoke in the review said they often found information online “that describes normal adolescent discomfort as a possible sign of being trans and that certain influencers have a substantial impact have had an impact on their child’s beliefs and understanding of their gender”.
The report quotes a young person who confirms this view, saying that “a lot of trans people make YouTube videos, which I think is an important source of information for a lot of people, and that’s mainly where I get my information from. not so much professional services”.
The report also stated that, according to another focus group of gender-questioning young people, they often found it difficult to “find reliable sources of information, with social media accounts preferred over mainstream news channels through experience”.
Greater social acceptance of transgender identities has made it easier for young people to come out, the study shows. It suggests that the increased numbers now reflect the true prevalence of gender incongruity in society.
Dangerous online influencers
Cass said her assessment team had received reports of children asking gender questions and being urged to keep things hidden from their parents. “We didn’t do extensive research, but certainly when we started hearing about certain influencers, I followed some of them,” Cass told The Guardian. “Some of them are giving them very unbalanced information.
“And some (young people) were told that parents would not understand, so they had to actively separate or distance themselves from their parents. All the evidence shows that family support is truly critical to people’s well-being. So there was really dangerous influence.”
Cass says the influencers “are legion,” but declined to identify any in particular.
Mental health
The marked increase in the number of young people with gender dysphoria should be seen in the context of rising rates of poor mental health and emotional problems among the wider adolescent population, especially among girls, the Cass report found.
There has been a substantial increase in mental health problems in children and young people, with increased anxiety and depression most evident in teenage girls, according to UK national surveys between 1999 and 2017.
The Cass review found there was a ‘marked increase’ in young women aged 16 to 24 presenting with anxiety, depression and self-harm. Some conditions – for example eating disorders – have increased more than others, especially in girls and young women.
Research into the number of cases of self-harm has shown a similar increase. For example, the report says there was an almost 70% increase in girls aged 13 to 16 engaging in self-harm. This was not seen in boys, the review said.
“The increase in presentations in gender clinics parallels to some extent this deterioration in the mental health of children and adolescents,” the report said. “Mental health problems have increased in both boys and girls, but are most noticeable in girls and young women.”
Girls were also more likely to have low self-esteem (12.8% versus 8.9% of boys), according to a study cited in the Cass Review. They were also more likely to be dissatisfied with their appearance (15.4% versus 11.8% of boys).
Changes in concepts of gender and sexuality
The report states that the relationship between sexuality and gender identity is “complex and contested,” and that while a trans identity does not necessarily determine a person’s sexuality, it was “important to consider the relationship between sexual identity and gender identity, as sexuality contributes to a person’s sense of identity, and both can be fluid during adolescence.”
The report cites a 2016 research paper from Gids that looked at sexual orientation in 57% (97) of a clinical sample of patients over the age of 12 for whom this information was available.
Of those registered at birth, 68% were attracted to women, 21% were bisexual, 9% were attracted to men and 2% were asexual. Of those registered at birth, 42% were attracted to men, 39% were bisexual and 19% were attracted to women.
The report goes on to say that it is “common in adolescence to be attracted to the same sex and not conform to gender stereotypes. To understand these feelings, young people must now navigate an increasingly complex interplay between sex and gender.”
On the relationship between sexual orientation and gender identity, the review concludes that this is “an area that warrants greater exploration and understanding.”
The report also noted that it had received several reports from parents of registered-at-birth women “that their child had gone through a period of trans identification before recognizing same-sex cisgender attraction.”