Dianna Kenny, PhD
The earliest written record from the town of Hamelin in Lower Saxony is from 1384. It states simply, “It is 100 years since our children left.” Historical accounts indicate that sometime in the 13th century, a large number of the town’s children disappeared or perished, though the details of the event remain a mystery. “The Pied Piper of Hamelin” is…the only Grimm’s fairy tale that is based substantially on a historical event. Both the actual event and the Grimm’s tale suggest an archetypal situation in which adults have allowed children to be seduced away into peril. This tale is a disconcertingly apt metaphor for various social contagions that have overtaken collective life throughout the centuries (Marciano, 2019, p. 345).
Although it is tempting to blame the phenomenon of social contagion on the digital age, in which people, young and old, remain symbiotically tied to their social media devices, eagerly scanning their screens for the latest news, fashion, holiday location, rave party, or dating site to assuage their “fomo” (i.e., fear of missing out), social contagion predated the advent of the cyberage, thereby placing its origins squarely in the minds of humankind, assigning social media to its role as an efficient conduit of contagion.
In 1774, Johann von Goethe (1990)published a novel, The sorrows of young Werther, in which an idealistic young man finds his actual life too difficult to reconcile with his poetic fantasies, including his unrequited love for his friend’s fiancée. He eventually becomes so depressed and hopeless by the perceived emptiness of his life, he commits suicide. Goethe was able to capture the nameless dread and endless longing of the human condition so well that his novel spawned a number of suicides, committed in the same way that Werther had killed himself, by shooting (Phillips, 1974). Such was the alarm created by this phenomenon, the book was banned in several European cities.
Two hundred years later, in 1984, the suicide of a young Austrian businessman, who threw himself in front of a train, initiated a spate of similar suicides that averaged five per week for nearly a year. Sociologists argued that this alarming occurrence was amplified by media coverage that glamorised suicide by providing graphic images of the suicidal act and details of the young man’s life. When media exposure of the event was curtailed and then stopped completely, the suicide rate dropped by 80 percent almost immediately. Although the influence of suggestion and imitation on suicide rates was dismissed by Durkheim (2005, 1897), Phillips’s (1974) work indicated that these factors do indeed play a significant role in the increase in suicides following a publicised suicide.
In 1841, a Scottish journalist, Charles Mackay (2012)wrote a book entitled Extraordinary popular delusions and the madness of crowds. In the preface to the first edition of the book, the aim of writing it is stated thus:
…to collect the most remarkable instances of those moral epidemics … to show how easily the masses have been led astray, and how imitative and gregarious men are, even in their infatuations and crime (p. 1)…Popular delusions began so early, spread so widely, and have lasted so long, that instead of two or three volumes, fifty would scarcely suffice to detail their history... The present may be considered…a miscellany of delusions, a chapter only in the great and awful book of human folly (p. 3).
The preface to the second edition in 1852 continued this theme:
Nations,… like individuals, …have their whims and their peculiarities; their seasons of excitement and recklessness… whole communities suddenly fix their minds upon one object and go mad in its pursuit; …millions of people become simultaneously impressed with one delusion, and run after it, till their attention is caught by some new folly more captivating than the first. At an early age in the annals of Europe its population lost their wits about the sepulchre of Jesus and crowded in frenzied multitudes to the Holy Land; another age went mad for fear of the devil and offered up hundreds of thousands of victims to the delusion of witchcraft... the belief in omens and divination of the future… defy the progress of knowledge to eradicate them entirely from the popular mind… Men… think in herds; …they go mad in herds, while they only recover their senses slowly, and one by one [Author’s italics] (p. 7).
Mackay’s book is about popular delusions and the madness of crowds. Today, we use the term social contagion to describe the “spread of phenomena (e.g., behaviours, beliefs and attitudes) across network ties” (Christakis & Fowler, 2013, p. 556). Using very large datasets (e.g., Framingham Heart Study) that have collected longitudinal data on original participants (Original cohort), as well as their children (Offspring cohort) and their children’s children (Third generation cohort) and including their spouses, siblings, friends and neighbours, Christakis and Fowler have shown that social network effects, known as clustering, remain strong and can extend to those up to three degrees of separation from the original cohort. Such effects have been demonstrated across a large range of factors by different researchers using differing datasets. Examples include overweight/obesity, sleep patterns, smoking, alcohol abuse, alcohol abstention, marijuana use, loneliness, happiness, depression, cooperation, and divorce among others.
Social network analysis, the method applied to study contagions of all kinds, was first developed and used in public health as a way of determining the spread of diseases (e.g., influenza, HIV/AIDS) that resulted in pandemics. It was subsequently applied to the challenges of introducing changes and innovations in the health system (Blanchet, 2013). Its applications have since expanded with the advent of computers, the internet, mobile and smart phones, and social media. Members of a network play different roles in the dissemination of innovations. A small number will adopt early (i.e., early adopters). Some of these will become opinion leaders who are central to the network who contaminate their “peers” (homophily) who in turn will influence those others at different levels of the network.
There are three types of social networks; (i) egocentric (networks assessing a single individual); (ii) sociocentric (social networks in a well-defined social space, such as a hospital or a school); and (iii) open system networks (e.g., globalised markets, social media). Each network consists of nodes (members), ties (between nodes), and measures of centrality, density and periphery or distance between the nodes. Networks with high centrality are the most effective in disseminating information or innovation. A key example with respect to this discussion is the transactivist lobby that has achieved spectacular success in a short time in changing health care, educational practices and legislation related to transgender individuals. Other characteristics of networks include cohesion (number of connections within a network) and shape (distribution of ties within the network) (Otte & Rousseau, 2002).
In this article, I explore the influence of social contagion on the disquieting upsurge in the number of children and young people whose parents are presenting to gender clinics around the world for advice regarding social transition, puberty blocking agents, cross sex hormones, and ultimately surgery in an attempt to change their gender. First, I examine the concept of social contagion and the mechanisms by which it influences behaviour and attitudes. Then I review three key adolescent behaviours that have been shown to be subject to social contagion. Finally, I demonstrate that the same principles of social contagion apply to the increase of young people who believe that they are transgender and are consequently seeking irreversible medical remedies to assuage their gender dysphoria. Finally, I explore the social contagion (i.e., clustering) of medical practice with respect to treatment of gender dysphoria, the precipitous legislation appearing in its support, and changes to policy and practice in education and sport, despite our collective failure to date to fully understand the phenomenon of gender dysphoria and its rapid, epidemic-like spread in the Western world.
Peer contagion is a form of social contagion, defined as a process of reciprocal influence to engage in behaviours occurring in a peer dyad that may be life-enhancing (e.g., taking up a sport, studying for exams, health screening, resisting engaging in negative behaviours, altruism) or life-compromising (e.g., illegal substance use, truanting from school, aggression, bullying, obesity). Peer contagion has a powerful socializing effect on children beginning in the pre-school years. By early childhood, the time spent interacting with same-age playmates frequently exceeds time spent with parents (Ellis, Rogoff, & Cromer, 1981). Further, characteristics of peer interactions in schools (e.g., aggression, coercive behaviours, mocking peers) are carried over into the home environment (Patterson, Littman, & Bricker, 1967). By middle childhood, gender is the most important factor in the formation of peer associations, highlighting the significance of gender as the organizing principle of the norms and values associated with gender identity (Fagot & Rodgers, 1998).
(i) Deviancy training as a mechanism of social contagion
Different mechanisms of transmission of peer influence have been identified. Deviancy training, in which deviant attitudes and behaviours are rewarded by the peer group have a significant effect on the development of antisocial attitudes and behaviours such as bullying, physical violence, weapon carrying, delinquency, juvenile offending, and substance abuse (Dishion, Nelson, Winter, & Bullock, 2004). Aggression in adolescence becomes more covert and deliberate and takes the form of exclusion, spreading rumours, and suborning relational damage among an adolescent’s friendship network (Sijtsema, Veenstra, Lindenberg, & Salmivalli, 2009). Interestingly, adolescents associated with peers who engage in instrumental aggression became more instrumentally aggressive, while those associated with peers who engaged in relational aggression became more relationally aggressive, demonstrating the specificity of the effects of peer contagion via the deviancy training.
(ii) Co-rumination as a form of social contagion
Another form of peer contagion in adolescence is co-rumination, a process of repetitive discussion, rehearsal and speculation about a problematic issue within the peer dyad or peer group that underlies peer influence on internalizing problems such as depression, anxiety, self-harm, suicidal ideation and suicide (Schwartz-Mette & Rose, 2012). Co-rumination is more common among adolescent girls (Hankin, Stone, & Wright, 2010)although a similar phenomenon among boys has been observed. Being in a friendship that engages in perseverative discussions on deviant topics has been associated with increased problem behaviour over the course of adolescence. The longer these discussions, the greater the association with deviant behaviour in later adolescence (Dishion & Tipsord, 2011).
Peer contagion may undermine the effects of positive socializing forces such as schools, rehabilitation programs for young offenders, and treatment facilities for eating disorders among others. Collecting same-minded adolescents into group programs may be counter-productive because the peer influence impacts of a homogeneous peer group to maintain disordered behaviours may be greater than the program effects of the treatment facility (Dishion & Tipsord, 2011).
Young people are particularly vulnerable to peer contagion if they have experienced peer rejection, hostility and/or social isolation from the peer group (Light & Dishion, 2007). On the contrary, protective factors against peer contagion effects include secure attachment to parents, adequate adult supervision and oversight of the young person’s activities, school attendance, and the capacity for self-regulation (T. W. Gardner, Dishion, & Connell, 2008).
(iii) Does social contagion have a causal effect on behaviour uptake?
Establishing a causal role for the effect of peer behaviour on adolescents is difficult because adolescents choose their peer networks; that is, they choose to associate with like-minded adolescents and those exhibiting similar attributes (homophily). This raises the question: Do adolescents choose their peers because they sanction and engage in similar behaviours or can peer social networks explain the uptake of (new) behaviours in individuals in the network? Sophisticated statistical models have been used to tease out the relative contributions of peer selection and peer influence. Correctly attributing the effects of these two factors has important policy implications since most interventions for reducing risky behaviour among adolescents are implemented at a school level (Ali & Dwyer, 2010).
Three possible causes of peer effects have been enumerated by Ali, Amialchuk, & Dwyer (2011):
i. Endogenous effect. This effect would occur in a situation in which “…an individual is more likely to use marijuana if there is a high rate of marijuana usage among the reference group because friends’ engagement in such activities could develop a social norm which might compel an individual to use drugs in order to fit in with one's peer” (p. 2), a process described as induction (Christakis & Fowler, 2013), colloquially described as “birds of a feather flock together.”
ii. Exogenous or shared contextual effect.This effect occurs when other social factors influence adolescent behaviour; for example, high substance abuse in a community population of adults, in which the adolescent’s parents are also substance abusers. In such a scenario, adolescents whose parents abuse substances will be more likely to abuse, and contagion may occur in adolescents as a result of peer influence even in those whose parents do not abuse substances.
iii. Correlated effect:These effects, known as environmental confounders, occur when adolescents in the same group behave in a similar way due to a third, perhaps unobserved factor, such as socioeconomic or demographic variables that cause their attributes to covary.
iv. The special case of social contagion via social media
In the world of social media, social contagion takes on a new, less complex and narrower meaning:
“Unlike the broadcasts of traditional media, which are passively consumed, social media depends on users to deliberately propagate the information they receive to their social contacts. This process, called social contagion, can amplify the spread of information in a social network” (Nathan & Kristina, 2014, p. 1).
Evidence for social contagion among adolescents
In this section, I review the evidence for social contagion among adolescents for three key psychopathologies that arise in adolescence (eating disorders, marijuana use and suicide) and compare the mechanisms of social contagion in these well documented areas with evidence for social contagion effects in gender dysphoria.
i. Anorexia nervosa
A number of researchers have identified the central role of social contagion in the development and propagation of anorexia nervosa in adolescent girls (Allison, Warin, & Bastiampillai, 2014). Adolescence is a time in which the focus on oneself becomes intense, and for some, critical and unrelenting. The developing female body constitutes one of the main objects of scrutiny. When this scrutiny is compounded by the collective inspection of all of one’s body’s flaws, the peer group becomes a powerful crucible for both the development and maintenance of disordered eating.
Intensification of peer influence in closed communities of like individuals, such as schools, inpatient wards, residential units (Huefner & Ringle, 2012), or therapy groups often results in the advocacy of the practices (e.g., self-starvation, compulsive exercise, deceitful practices around eating) associated with anorexia nervosa (Dishion & Tipsord, 2011).
If we add social media and online networks as further sources of influence, affected adolescents can effectively surround themselves exclusively with like minds, thereby normalising cognitive distortions around eating and body image and making recovery very difficult. These effects are further compounded by the high status of thinness in western culture, and an ubiquitous focus on nutrition and exercise. Originally thought to be caused by genetics and pathological family dynamics, this view was revised with the finding, using longitudinal study designs and social network analyses, that same-gender, mutual friends were most influential in the development of obesity in adulthood, with siblings and opposite-sex friends having no effect (Christakis & Fowler, 2007).
ii. Marijuana use among adolescents
Substance use amongst adolescents is a major public health issue (Fletcher, Bonell, & Hargreaves, 2008), with a population study conducted by the Center for Disease Control and Prevention showing that 10 percent of youths reported using illegal substances before the age of 13, with marijuana the most frequently used substance (Chen, Storr, & Anthony, 2009). Peer influence has long been suspected as a stimulus that amplifies risky behaviours in the social network (Clark & Loheac, 2007; Lundborg, 2006).
Using the National Longitudinal Study of Adolescent Health (Add Health) (n=20,745) representing a sample of adolescents from grades 7-12 in 132 middle and high schools in 80 communities across the USA examined the influence of peer networks in the uptake and continued use of marijuana. The peer group was identified by the nomination of close friends and classmates within a grade were used to identify the broader social network from which friends were chosen (Ali et al., 2011).
Results showed that for every increase in marijuana use of 10 percent in adolescents in a close friend network increased the likelihood of marijuana use by two percent. An increase of 10% in usage in grade peers was associated with a 4.4 percent increase in individual use. Reporting a good relationship with one’s parents, living in a two-parent household and being religious were protective against marijuana uptake. When peer selection and environmental confounders were held constant, increases in close friend and classmate usage by 10 percent both resulted in a five percent increase in uptake in individuals within those networks.
Although social ties are generally protective against loneliness, depression and suicide, social ties can be toxic and can amplify the risk of psychopathology in members of a social network (Christakis & Fowler, 2008). Exposure to the suicidal ideation or suicide attempts of significant others increases the risk of suicidality in other network members (Abrutyn & Mueller, 2014). Experiencing self-harm or suicide at close quarters may erode the emotionally regulating effects of normative moral precepts against such behaviour (Mueller, Abrutyn, & Stockton, 2015). When vulnerable individuals share “ecologically bounded spaces” (p. 205) like schools or the family home, this may increase suicide contagion if social relationships within those spaces are psychopathological. Our emotional connections to members of our social networks is the mechanism through which social learning and the development of normative behaviours and attitudes are built. However, negative emotions are more “contagious” and thus exert a greater impact on members (Turner, 2007).
Celebrity suicides also trigger spikes in suicide rates, with the greater visibility of the celebrity and prolonged coverage of the suicide triggering higher spikes and longer duration of elevation of rates of suicide amongst fans (Fu & Chan, 2013; Stack, 2005). Similarly, Durkheim (1951)highlighted the phenomenon of suicide outbreaks or “point clusters” defined as “temporally and geographically bounded clusters” such as gaols, regiments, monasteries, psychiatric wards, and First Nations reservations (Mueller et al., 2015, p. 206). Individuals in such networks share a collective identity that appears to heighten subsequent suicides following the suicide of the first decedent (Niedzwiedz, Haw, Hawton, & Platt, 2014).
A well-documented example of a suicide “echo” cluster (an identical suicide cluster occurring within 10 years of a first cluster) occurred in two high schools in Palo Alto that, between them, had suicide rates four to five times higher than the national average. In 2009, three students committed suicide in a nine-month period by stepping in front of a commuter train. A fourth student committed suicide by hanging. In 2013 a mental health survey showed that 12 percent of students from these schools had seriously considered suicide in the previous 12 months. Thereafter, there was another spate of suicides, with three students taking their lives within three weeks of each other. A fourth committed suicide four months later by jumping off a tall building and a fifth followed shortly afterwards by walking in front of a train. Extreme perfectionism and pressure to excel at school, get into Stanford, make a lot of money, and be ostentatiously successful materially and intellectually were assessed to be far too great a burden for the more vulnerable students to withstand.
Using the same data set as the study examining marijuana use but following up four waves of these participants into adulthood, Wave IV assessed suicidality in young adults aged 24-32. This study showed that holding all other psychological risks constant, those young people having a role model who attempted suicide were more than twice as likely to report suicidal ideation in the following 12 months. Participants who had a friend or family member commit suicide were 3.5 times more likely to attempt suicide themselves compared with those who had no close associate attempt or commit suicide in the same 12-month timeframe. These effects were enduring. Young adults who reported an attempted suicide of a role model were more than twice as likely to report a suicide attempt six years after the role model’s attempt compared with their otherwise similar peers. Attempting suicide in adolescence increased suicidal ideation and suicide attempts in young adulthood. Significant risk factors for this association included experiencing emotional abuse in childhood, a diagnosis of depression, and a significant other attempting suicide. Thus, suicide contagion appears to be a significant risk factor for suicide in young adulthood but contagion in this study did not require bounded social contexts.
iv. Gender dysphoria
Commentators on the burgeoning incidence of young people claiming that they are transgender assert that peer contagion may underlie this ominous trend. However, it has rarely been systematically studied either theoretically or empirically. Given the strong evidence of peer contagion in suicide, substance abuse and eating disorders, especially among adolescents, the role of peer contagion in gender dysphoria demands urgent attention.
If we examine the gender dysphoria epidemic in social network terms, we see several features operating. It is an open-system network with nodes and ties expanding across the oceans to the US, UK, Asia, Europe, Scandinavia, and Australia. Most countries are reporting sharp increases in the number of people seeking services and treatment for gender dysphoria. Many are ramping up services and setting up new gender clinics to cope with demand. This network is highly centralised with only one voice – the transactivist lobby - being heard above the desperate whispers of terrified parents and horrified academics, doctors, psychologists and psychotherapists. Opinion leaders operating at the centre of these networks are very influential. The level of density in a network has two effects – firstly, it enhances the circulation of information between members and secondly, it blocks the introduction of dissenting ideas and evidence (Iyengar, Van den Bulte, & Valente, 2011).
The field is too young to have attracted researchers to undertake social network analyses to assess peer contagion effects in gender dysphoria. Hence, formal empirical studies have not yet been conducted. However, there is evidence from several sources that peer contagion may be a relevant factor in the sharp increases in young people presenting with gender dysphoria.
(i) Low gender typicality, peer victimization, ingroups and the trans-lobby
Low gender typicality (i.e., perceived lack of fit within one’s binary gender) has a significant impact on social acceptance within one’s peer group (Sentse, Scholte, Salmivalli, & Voeten, 2007). It is strongly associated with adjustment difficulties, behavioural problems, lower self-esteem, and increased internalizing disorders (e.g., anxiety, depression) (Smith & Juvonen, 2017). As children progress to adolescence, peer as opposed to parental acceptance becomes paramount. Peers therefore take over the role of gender socializing agents from parents (Blakemore & Mills, 2014). Adolescent peers tend to be critical of behaviours, dress, mannerisms and attitudes that are not gender typical as a way of policing and reinforcing gender norms and respond with criticism, ridicule, exclusion and even intimidation of non-conformers (Zosuls, Andrews, Martin, England, & Field, 2016). The problems accruing to low gender typicality are mediated by peer victimization. Reducing peer victimization may ameliorate these difficulties (Smith & Juvonen, 2017). Conversely, peer acceptance mediated the self-worth of gender non-conforming 12- to 17- year-olds (Roberts, Rosario, Slopen, Calzo, & Austin, 2013).
Gender non-conformity and gender atypicality have also been associated with higher physical and emotional abuse by caregivers (Roberts, Rosario, Corliss, Koenen, & Austin, 2012). Mental health is difficult to sustain in the face of caregiver abuse and peer bullying and victimization (Aspenlieder, Buchanan, McDougall, & Sippola, 2009). Indeed, gender non-conforming and gender atypical youth are at higher risk of depression, anxiety and suicidality in adulthood (Alanko et al., 2009).
It is tempting to speculate that these groups of young people, searching for homophily (i.e. like peers) started to exaggerate their points of difference from their gender-conforming peers rather than to hide and minimize them to avoid being bullied and excluded. In so doing, they left the “outgroup” of nonconformers and formed an ingroup of extreme gender-nonconformers, transcending the gender barrier altogether and declaring themselves transgender. Suddenly, the discomfort and fear of not being gender typical becomes a virtue and rather than fearing the disapprobation of their peers, their open revolt in declaring themselves transgender is valorised by a politically powerful transactivist lobby. One would expect that gender atypical children who feel both internal and external pressure to be gender conforming would experience greater discomfort (Carver, Yunger, & Perry, 2003)and therefore be more susceptible to the message of transactivism.
Ingroups behave in stereotypical ways with respect to outgroups – they favour ingroup characteristics, assigning more positive attributes to its members and derogating outgroups in order to enhance the status of their ingroup (Leyens et al., 2000). It is not surprising, then, that members of the transgender ingroup exaggerate the characteristics of the “trans” gender they take on – becoming more “feminine” or “masculine” than heteronormative groups of cismen and ciswomen. Transactivist groups have proliferated and consolidated in a short time by exploiting the characteristics of ingroups and outgroups. For example, social projection (i.e., the belief that other members of the group are similar to oneself) has been a powerful integrating process that simultaneously creates protection for its own members and distance from outgroup members, using the formula, “if you are not with us, you are against us” – those disagreeing with the ideology of the trans-lobby are labelled “transphobic” and publicly denounced.
(Ii) Rapid onset gender dysphoria (ROGD) and the role of social media
The upsurge in rapid onset gender dysphoria (ROGD) tends to occur mostly in girls at around the age of 14 years, which is an age identified by developmental psychologists to be particularly susceptible to peer influence (Steinberg & Monahan, 2007). For example, a study of peer contagion for risky behaviours found that exposure to risk-taking peers doubled the amount of risky behaviour in middle adolescents, increased it by 50% in older adolescents and young adults, and had no impact on adults (M. Gardner & Steinberg, 2005). This group of young people were likely to belong to peer groups in which one or more of their friends had become gender dysphoric or transgender-identified. Their coming-out announcement to parents also tended to be preceded by recent increases in their daughters’ social media and internet usage. Clinical practice also identifies peer bullying and a romantic disappointment as possible triggers to ROGD. It is only a small step to understanding the social contagion of ROGD in this age group.
Littman (2019)canvassed the perceptions of parents who had children who displayed ROGD during or just after puberty. There were 256 respondents, of whom 83% had daughters, with a mean age of 15.2 years when they declared themselves transgender, 41% of whom had previously expressed a non-heterosexual sexual orientation, and 62.5% of whom had received a diagnosis for a mental health disorder (e.g., anxiety, depression) or a neurodevelopmental disability (e.g., autism spectrum disorder). Thirty-seven percent (37%) of these young people belonged to peer groups with other members identifying as transgender. Parents also reported a decline in their child’s mental health (47%) and relationship with parents (57%) after declaring themselves transgender. Thereafter, they preferred transgender friends, websites, and information coming from the transgender lobby.
An indicative case study was written up in an article for The Atlanticby Jesse Singal (2018), in which Claire, a 14-year-old girl decided she must be trans because she was uncomfortable with her body even after she restricted her food intake, was finding puberty uncomfortable, had difficulty making friends, was feeling depressed and was lacking in self-confidence. Against this backdrop of woes, she came across MilesChronicles, thewebsite of an omnipotent and histrionic transboy, now a young transman. Watching this video resulted in Claire pouring all her sadness and unease about herself into the “realisation” that she was really a “guy.” Miles made transitioning appear easy and simple, was effusive in his praise of his new self and supportive of others to follow suit. This is a very common scenario reported by parents of teenage girls with ROGD.
Such websites, all easily accessible to vulnerable adolescents, can have a very persuasive effect on viewers. Recent studies show that contagion is enhanced when the influencer is perceived to have high credibility and reduced when the influencer is perceived to have low credibility. A similar effect is observed if the influencer belongs to an out-group or an in-group (Andrews & Rapp, 2014). Miles is the quintessential trans pinup icon with a “You can be just like me if you transition!” message.
Following YouTube posts and social media with respect to the transgender debate over the past couple of years, I have noticed that posts that depict young people struggling with their gender identity or questioning their decision to take puberty blocking agents and cross-sex hormones, or to undergo what is euphemistically called sexual reassignment surgery are rapidly taken down so that only a homogenous message which matches the strident messaging of the transactivist lobby is on display in the ether.
(iii) Empirical evidence
There has been a sharp increase in the population estimates of those identifying as transgender. One study, a meta-regression of population-based probability samples provides compelling evidence of this trend, where estimates have more than doubled in the space of eight years from 2007 to 2015.
Source: Meerwijk, E. L., & Sevelius, J. M. (2017). Transgender population size in the United States: a meta-regression of population-based probability samples. American Journal of Public Health, 107(2), e1-e8. https://ajph.aphapublications.org/doi/pdfplus/10.2105/AJPH.2016.303578
Data from Australia also show an upward trajectory in the number of children enrolled in gender clinics in the four states of Australia that offer a gender service. The noteworthy feature of this graph (Figure 2) is that three of the four states (WA, Queensland and Victoria) show similar increases over the five-year study period (2014-2018). Although figures in NSW increased, the magnitude of absolute numbers was significantly lower than for the other three states. Victoria had the largest numbers and the largest increases. It is also a state where the trans lobby has been particularly vocal and where the concept of the "safe schools"policy was conceived and implemented.
Source: Kenny, D.T. (2019). Child and adolescent gender dysphoria in Australia – adopting the Zeitgeist but where are we going? Invited paper to the NSW parliamentary forum, Parliament House, Sydney, Australia, 2 July.
V. Social contagion in treating practitioners, legislators, and educators.
i. Treating medical practitioners
Iyengar, Van den Bulte, and Valente (2011)found contagion in the prescribing patterns of doctors after controlling for marketing outreach and systemic changes, such as the advent of new drugs and changes in the prevalence of diseases. Shared geographical proximity, shared group membership and self-identified ties between doctors were all factors in behavioural contagion, with self-identified ties the most compelling factor. A critical factor in marketing attempts to manipulate uptake of a new drug or medical treatment is the identification of those in the network who are influential and those who are influenceable - without individual uptake, the marketing campaign will falter (Christakis & Fowler, 2011). Central figures in the network have a stronger tendency to adopt early. Of course, network contagion effects may be modified by product characteristics, for example, the perceived effectiveness and perceived safety of the new drug.
A few salient examples regarding government policy and legislation and changes in educational practice include the following:
ii. Law and Legislation
Transgender activists in several countries have succeeded in persuading gender clinics to commence social transition in children as young as two and three years of age (e.g., Royal Children’s Hospital, Melbourne, Australia), followed by the administration of puberty blockers at nine or 10 years of age. They have also been successful in lowering the age limit at which young people can access sex re-assignment surgery without parental consent. For example, in Oregon, USA the lower age limit for surgery has been removed with parental consent and lowered to 15 without parental consent (Medical Daily on parental consent). It is almost commonplace to read adolescent girls as young as 14 years undergoing double mastectomies (Rowe, 2016). Recently, a judge in Canada found a father potentially guilty of domestic violence if he continued to use his 14-year-old child’s birth name and female pronouns. This child is petitioning the court to commence cross-sex hormones in the face of his father’s strong objection (The Guardian on Canadian case). The lower court ruled that a minor is capable of giving consent to medical procedures. Accordingly, the child has commenced testosterone while the battle continues in the Court of Appeal.
Other legislative support e.g., Victorian Births, Deaths and Marriages Registration Amendment Bill 2019 for the transgender epidemic includes a bill allowing transgender people to change their birth certificates without undergoing sex-reassignment surgery (The Guardian on birth certificates). Under the legislation a person can self-nominate their sex and list as male, female or any other gender diverse or non-binary descriptor of their choice. Children can alter the sex on their birth certificate with parental support and a statement from a doctor or registered psychologist saying the decision is in the best interests of the child.
An article published by the Family Court of Australia (Family Court of Australia report) provides legal reasoning and argument regarding the disposition of gender dysphoria treatment for minors that outlines the limits of legal intervention in these cases. The reasoning in this report is underpinned by current, often erroneous information about gender dysphoria. In re Kelvin, the Royal Children’s Hospital, Melbourne gave evidence that there was growing consensus regarding medical treatment of gender dysphoria. The RCH over-stated its positive outcomes but did not refer to the uncertainty and disagreement about treatment and outcomes expressed by a growing number of researchers and clinicians.
Two Amicus Briefs, each supporting contrary arguments, were presented to the Supreme Court of the United States. They can be found at Amicus Brief 1 and Amicus Brief 2. The interested reader is invited to study both briefs and decide which of the two is more convincing.
The Australian Human Rights’ Commission has provided guidelines about sports participation that clearly disadvantage natal females and which may well have a profound effect on female participation in sport (AHRC sport guidelines). It was written with the participation of peak sports’ bodies including Coalition of Major Professional and Participation Sports (COMPS) and Sport Australia. The document purports a victory for “diversity and inclusion.” The reality is that these guidelines neutralise the protections provided to females in the Commonwealth Sex Discrimination Act,1984. A critique of the bill can be found at Critique of sport guidelines.
The NSW Department of Education has issued a Bulletin (Bulletin 55- Transgender Students in Schools) Bulletin 55, NSW Department of Education that deprives parents of any rights in the management of their gender dysphoric child at school. Bulletin 20 even deprives parents of parental authority regarding the registered name of their child (Bulletin 20). It states,
If either or both parents object to the change to the way the first name is recorded by the school, the principal needs to make a decision about what is in the child’s best interests. This decision should have regard to the age, capability and maturity of the student and can be informed by advice from a health care professional about the potential impact on the student’s wellbeing of declining to use and record the student’s preferred first name.
These guidelines undermine parental authority in the child’s eyes, setting a dangerous precedent allowing children to make decisions about their wellbeing for which they are not prepared.
“All the world is queer save thee and me, and even thou art a little queer.” When the Welsh reformer and philanthropist Robert Owen penned these words in 1771, the word “queer” meant “strange” or “different.” The word “queer”is nowan over-arching term used to describe sexual and gender minorities. I wish to revert to the original meaning of this word in the context of this paper as it highlights yet another worrying psychic epidemic that has spread its tendrils into all corners of society – medical, social, legal, psychological, political, ideological and philosophical. Parents are not exempt from these influences; there are numerous websites offering support to parents of transgender children (e.g.Transcend; Human Rights Campaign; Gender Centre; Gender Help for Parents).
By the time the proponents of gender dysphoria in children and adolescents realise the far-reaching damage they have caused by their unthinking political correctness in supporting gender affirmation, the courts will be clogged with lawsuits brought by transgender adults whose bodies and minds have been irreparably damaged by the zealous compliance to the strident voices of the trans lobby.
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Paper presented at the Forum on transgender children and adolescents at the Parliament of NSW, 2 July, 2019
Professor Dianna Kenny
Precise data regarding the frequency of people with gender dysphoria or who identify as transgender have been difficult to source. In attempting to count the transgender population, decisions need to be made about whom to include. For example, some people identifying as transgender live with their gender incongruence and do not seek treatment. Others make a social but not a medical transition, while others make social and medical transitions but not a surgical transition. Some attempt to transition medically outside of the public health system by sourcing cross-sex hormones on the internet and other non-medical suppliers, while others visit their GPs or endocrinologists to obtain medications rather than presenting to specialised gender clinics, often because of the onerous waiting times for an appointment and/or perceived or actual barriers to accessing treatment.
In the USA, the rate of self-identification as transgender doubled in 10 years from 12.5 (0.013%) (2002) to 23 (0.023%) per 100,000 (2011). The Massachusetts Behavioral Risk Factor Surveillance Surveyfound that 0.5% of the adult population aged 18 to 64 years identified as TGNC (transgender and gender nonconforming) between 2009 and 2011. By 2016, the estimated rate of the USA population identifying as transgender was 0.6% (i.e., 1.4 million people)compared with 0.3% in 2011. By 2017, self-reported transgender identity in children, adolescents and adults ranged from 0.5 to 1.3%, rates that are significantly higher than prevalence rates based on clinic-referred samples of adults.
Attempts to estimate the true transgender population in the USA using meta-regression of 12 population-based probability samples (national surveys) conducted over the years 2007-2015 concluded by extrapolation that there were 390 per 100,000 (0.39%) transgender individuals in the US population. Given that more than 50% of the respondents were in younger age groups, (e.g., 18-31), the authors stated that it may be a more reliable estimate for younger transadults than for the population.
Similar, more pressing difficulties have been encountered in identifying the “true” number of children and young people identifying as gender dysphoric under the age of 18 years in Australia. In the New Zealand Adolescent Health Survey(Youth 2012), a national, cross sectional, population-based survey of 8,166 secondary school students, 1.2% (98) students reported being transgender, 2.5% (204 students) reported not being sure about their gender and 1.7% did not understand the question. Young people (n=719) in Finland aged 16-18 completed a survey using the GIDYQ-A (Gender Identity Disorder Youth Questionnaire) in 2012-2013 and the survey was replicated in 2017 on 1,007 young people. In the 2012 survey, 2.2% of males and 0.5% of females reported possibly clinically significant GD. In 2017, 3.6% males and 2.3% females reported possibly clinically significant GD.
The Royal Children’s Hospital’s Gender Service, Melbourne reported a 250-fold increase in new referrals to their service between 2003 and 2017(from one to 250). A similar increase has been noted in the referral rates to the Tavistock Clinic in the UK. The figure below shows the increases at Tavistock Clinic over the years 2007-2016.
Number of young people under 18 years of age referred to the Gender Identity Development Service
Figures from the Gender Identity Development Service (GIDS), which is the NHS’s only facility for children with gender dysphoria in the UK, showed that 84 children between three and seven years were referred in 2017, compared with 20 in 2012/2013. Referrals of children younger than 10 years of age showed a fourfold increase from 36 in 2012 to 165 in 20168. In 2016, there were 2,016 referrals for children aged between three and 18 years, a six-fold increase from 314 five years previously. More than twice as many girls as boys are referred to such service. There has been a linear relationship between increasing media coverage, increasing stridence from the transactivist lobby and the numbers of children and young people presenting to gender clinics around the world(BBC news, 2016). The Tavistock and Portman NHS Trust, the only gender treatment facility in the UK reported that the number of under-18s who visited the clinic between 2015 and 2016 had risen by 25% to 2,519.
Promotional material on the website of the Royal Children’s Hospital (RCH) Melbourne claims that 1.2 percent of Australian school children (i.e., 45,000 children) “are thought to identify as transgender”.It is unknown whether this is an extrapolation from the New Zealand study. The Australian Bureau of Statistics (ABS) Census of Population and Housing, 2016,identified 1,260 adult individuals who stated that their sex/gender was other than male or female, a rate of 5.4 per 100,000 (0.0054%). Of these 1,260 adults, 340 (27%) identified as either transmale (n=70), transfemale (n=100), or transgender (n=170), i.e., 1.5 per 100,000, a rate vastly smaller than the declared rates for children and young people by RCH, Melbourne. For example, a study by Quinn and colleagues, reported that children and youth aged between three and 17 years constituted more than 20 percent of the transgender population.
To gain more clarity regarding the frequency of children seeking services for gender dysphoria in the Australian population of children and young people, more precise figures were sought from the key child and adolescent gender services around Australia.
The data forming the basis for this study were obtained through Freedom of Information applications made in the four jurisdictions providing gender services to children in Australia by Greg Donnelly MLC, Parliament of New South Wales. As there were virtually no treatment facilities for children with gender dysphoria in Australia prior to 2014, the study period was identified as the five years between 2014 and 2018. Currently, there are four medical institutions offering services and these are listed below, together with their eligibility criteria.
Eligibility: Children aged under 18 years, living in Queensland, seeking support with their gender identity, referred by local doctor/general practitioner.
Eligibility:Children >9 years and/or displaying signs of puberty can be referred to Westmead Children’s Hospital for gender dysphoria review; referred by GP, paediatrician, psychologist, or psychiatrist to the Adolescent Mental Health unit at Westmead Children’s Hospital.
Eligibility: Children and adolescents aged between three and 17 years of age with concerns about gender identity. Referral from GP required. Young people over the age of 17 years may access adult services (i.e., Monash Medial Centre Gender Clinic).
Eligibility: Any child or young person up to the age of 18, who resides in Western Australia, with concerns regarding their gender, gender non-conforming behaviour or gender dysphoria, can be referred to the Gender Diversity Service for consultation.
Three outcome measures were assessed, as follows:
For each measure total numbers, percent total per state, and increase in incidence by year and state were calculated. Percentages of children seeking treatment for gender dysphoria and the proportion of children from the general population aged 5-19 years in WA, Qld, Vic and 10-19 in NSW were compared to ascertain possible over- and under-representation of children in each state seeking treatment or receiving stage 1 or stage 2 treatment were calculated using the chi-square test of proportions.
Over the five-year period 2014-2018, 2,415 children and young people were enrolled in one of these four gender clinics in Australia. Except for 2014, these numbers may not represent unique cases, because some children remain enrolled over consecutive years. Therefore, these figures are indicative only of the increase in numbers over the study period. These data are presented graphically by year and state (Figure 1).
Figure 1 one shows that numbers of children and young people enrolled/seeking treatment for gender dysphoria over the five-year period 2014-2018 in each of the four states of Australia with gender clinics increased for each state but not uniformly. The absolute numbers for NSW were significantly lower compared with the other three states. Table 1 summarises the numbers by state and year, the total numbers for each year, the percent of young people attending in each state and the rate increase for each state.
Table 1 Number of children seeking services from gender clinics in four states of Australia and rate of increase since 2014.
The incidence of treatment seeking across the four clinics increased more than 11 times over the study period.
Table 2 Percentage of children seeking treatment for gender dysphoria and proportion of children from the general population aged 5-19 years in WA, Qld, Vic and 10-19 in NSW
Although the population figures only provide an approximation of the population from which children presenting to GD clinics are drawn, the chi square comparison of proportions test identified disparities between expected and actual proportions. For NSW, the difference of -14.9% was significant (Chi-sq=273.5, df=1, p<0.0001; for Queensland, the difference of -2.4% was significant (Chi-sq=6.9, df=1, p<0.008) indicating under representation; for WA, the difference of +8.7% was significant (Chi-sq=151.5, df=1, p<0.0001; for Victoria the difference of +8.6% was significant (Chi-sq=81.9, df=1, p<0.0001) indicating over representation.
Figure 2 shows numbers of children and young people receiving puberty-blocking agents in these four gender clinics over the five-year period 2014-2018 in each of the three states of Australia [Note: Victoria failed to provide these figures]. Figures rose sharply for Queensland but not for the other two states for which figures were available.
Note 1: Figures for Victoria 2018 were not provided
Note 2: Figures for Queensland are based on Queensland Children’s Hospital (QCH) pharmacy reports only. They do not include young people accessing medication outside the QCH pharmacy. Hence, these figures are an under-representation of the true number receiving cross-sex hormones. This may also be the case in other states; they do not include children receiving GD treatments through the private health system.
Over the five-year period 2014-2018, 492 children and young people were receiving puberty blocking agents (stage 1 treatment) from these three gender clinics in Australia (Victoria did not supply figures). Victoria (see Table 3) provided the numbers of young people who commenced on puberty-blocking agents in four of the five years requested, as follows:
Table 4 presents the total numbers of young people receiving puberty blockers by state (NSW, WA, Qld) and year.
Table 4 Number of children receiving puberty blocking agents (stage 1 treatment) from gender clinics in three states of Australia 2014-2018.
Table 5 compares the proportions on PBA by state with population proportions.
Table 5 Percentages of children taking puberty blocking agents for gender dysphoria and proportion of children from the general population aged 5-19 years in WA, Qld, Vic and 10-19 in NSW
The chi square comparison of proportions test identified disparities between expected and actual proportions. For NSW, the difference of -3.2% was not significant (Chi-sq=2.6, df=1, p<0.12; for WA, the difference of +0.4% was not significant (Chi-sq=0.07, df=1, p<0.79; for Queensland, the difference of +24.6% was significant (Chi-sq=149.5, df=1, p<0.0001). Queensland is significantly proportionately disparate from the other two states, i.e., it has 2.2 times the number of young people taking PBA than expected from the population.
Over the five-year period 2014-2018, 286 children and young people were commenced on cross-sex hormone (stage 2) treatment at one of these four gender clinics in Australia.
Figure 3 shows the number of children in each of the four gender clinics who were receiving cross-sex hormones (stage 2) over the study period in each state.
Note 1: NSW supplied “0” in each data cell for each of the five years. A follow-up inquiry to Sydney Children’s Hospital Network (Ref No: SCHN18/7854, 6/8/19) indicated “Sydney Children's Hospitals Network (SCHN) does not and has not initiated stage 2 Gender Dysphoria treatment at The Children's Hospital at Westmead. [O]ccasionally SCHN sees a patient in a crossover transition phase who has had stage two treatment initiated by an adult physician, as The Children's Hospital at Westmead pharmacy is still providing the patient's treatment in that crossover phase. However, their primary care at this stage is under the adult physician who prescribes the stage two therapy. I can confirm that the zero response provided in the GIPA Notice of Decision is correct but that there may be instances in which children are receiving active stage 2 treatment elsewhere while still attending The Children's Hospital at Westmead clinic”.
Note 2: Figures for Queensland are based on Queensland Children’s Hospital (QCH) pharmacy reports only. They do not include young people accessing medication outside the QCH pharmacy. Hence, these figures are an under-presentation of the true number receiving cross-sex hormones from QCH.
Note 3: Figures for Victoria 2018 extrapolated from Victoria 2017 figures
Table 6 summarises the numbers by state and year, the proportions from each state and the increase in incidence from 2014 to 2018.
Table 6 Number of children receiving cross-sex hormones (stage 2 treatment) from gender clinics in four states of Australia 2014-2018.
The gender clinic in NSW did not count any young person proceeding to stage 2 treatment, explaining that those who did progress to stage 2 (cross-sex hormones) treatment were referred to adult services or private endocrinologists. These numbers are needed to further our understanding about the paths taken by young people exiting children’s services following stage 1 treatments.
In the other three states, there were sharp increases in the numbers of young people undergoing stage 2 treatment. For WA and Queensland, this occurred only in 2018; in Victoria this occurred in 2017, with a slight decline in numbers in 2018.
This paper presents available data on the numbers and patterns of referral to the four gender clinics for children and young people in Australia, and the number of children who were receiving stage 1 or stage 2 gender transition treatments during the study period (2014-2018). The dramatic increases in the number of children seeking services (between two and 11-fold increases over the five-year study period) concur with overseas data that also show sharp increases in referrals.
These data significantly under-represent the actual numbers of children receiving some form of treatment for gender dysphoria, given that only four of seven states have gender clinics and could supply data. Not all the available data were supplied from these, so even these data are incomplete. The numbers of children being treated for gender dysphoria in South Australia, Tasmania, Northern Territory and Australian Capital Territory could not be ascertained and could not therefore be included.
Despite this under-representation of actual cases of gender dysphoric young people seeking treatment, these estimates are discrepant from the number of adults identifying as transgender in the ABS Census of Population and Housing, 2016, from which population comparisons were accessed for this study. In that census, only 340 adults across Australia identified as transgender.
The four states from which data were collected showed significant differences in treatment patterns. What could account for the anomalies observed in these data between the four states?
One explanation for the lower enrolled/treatment-seeking numbers in NSW over the five-year study period is that NSW only accepts children older than nine years of age, compared with the other three states that either set no lower age limit for referral (Queensland and Western Australia) or set it at three years of age (Victoria). This is not a robust explanation as it would be unlikely that large numbers of children under the age of nine or 10 would be presented to such clinics. The other possible explanation is that some states are more meticulous in their initial assessment of the child and hesitate to conclude that the child requires gender affirming treatment before a thorough individual and family assessment has been undertaken to exclude those with other conditions that need to be treated. This may account for the lower numbers in NSW, the largest and most populous state in Australia.
What can explain the discrepancy in the number of children treated with puberty-blocking agents between Queensland and the other states offering gender services? It is highly unlikely that there would be actual differences in the incidence of gender dysphoria in children living in Queensland compared with children living in NSW or Western Australia. Possible explanations include differences in ideology, criteria for treatment, strong adherents to gender affirming treatment in the Queensland gender service and/or more socio-political pressure on treating practitioners in Queensland compared with other states.
Similarly, figures in Victoria showing 70 times increase over the study period of young people receiving cross-sex hormones is of great concern and requires urgent investigation. Given the relatively small numbers commencing on puberty-blockers in each year of the study period, the data suggest that those attending the Victorian service may be older, post-pubertal adolescents who are referred to other treatment facilities for their cross-sex hormones where they are not counted and are lost to follow-up.
Of equal interest is the large numbers of young people in Queensland who have been placed on puberty-blocking agents and the relatively small number on cross-sex hormones. Do the majority of these children desist from progression to cross-sex hormones or are they referred elsewhere for stage 2 treatments, which is the case for NSW and appears to be the case for Victoria? If the former, these results are in stark contrast to overseas research showing that once children commence puberty-blocking agents, most proceed to cross-sex hormones.If the latter, obtaining accurate numbers of those referred elsewhere for stage 2 treatments need to be recorded and made available to the research community and the public.
Sadly, these data stimulate many more questions than answers about the demographic of this population across the four states as well as the treatment protocols in each state that may affect how treatment is decided and delivered. They represent a first attempt to systematize data gathering in gender dysphoria treatment in young people in Australia. It has been difficult to obtain reliable information from the gender clinics and these data are necessarily incomplete because of a failure to supply the requested information in some cases or receiving inaccurate or ambiguous information in others. These data should therefore be treated as incomplete and preliminary. They are presented to stimulate concern and debate about the efficacy of such life-altering treatments for young people.
There is no doubt that the transactivist lobby has been spectacularly successful in their campaignto assert transgender rights and many in medicine, social policy, the media and the law have succumbed to their pressure to conform to a gender-affirming ideology without adequate evidence to support its application. These forces are no doubt at play in the pattern of numbers we see in this paper.
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[gonadotropin‐releasing hormone analogues(GnRHa)]
The total number of children aged five to 19 years in each of these four states of Australia was 3,813,130. In NSW, there were 1,369,618 young people aged between five and 19 years, 36% of the total. In Western Australia, there were 464,956 young people aged between five and 19 years, 12.2% of the total. In Queensland, there were 912,522 young people aged between five and 19 years, 23.9% of the total. In Victoria, there were 1,066,034 young people aged between five and 19 years, 28% of the total. The denominator is smaller for NSW because children must be >9 years to be referred to a gender service. N=891,434 represents the age groups 10-14 and 15-19 years in the Census. Hence, population proportions were adjusted to account for the reduction in numbers in NSW.
The Australian Bureau of Statistics presents age data in four-year blocks, 0-4, 5-9, 10-14, and 15-19. Because most gender clinics have an upper age limit of 18 years, these figures represent a small over-estimation of the population from which children presenting with gender dysphoria are drawn.
It may be the case as for NSW, that the RCH, Melbourne, treats only a small number of young people with stage 2 drugs, referring the majority to adults clinics or private specialists where they are not counted and are lost to follow-up.
The Australian Bureau of Statistics presents age data in four-year blocks, 0-4, 5-9, 10-14, and 15-19. Because most gender clinics have an upper age limit of 18 years, these figures represent a small over-estimation of the population from which children presenting with gender dysphoria are drawn.
De Vries, A. L., Steensma, T. D., Doreleijers, T. A., & Cohen‐Kettenis, P. T. (2011). Puberty suppression in adolescents with gender identity disorder: A prospective follow‐up study. The Journal of Sexual Medicine, 8(8), 2276-2283.
Bizic, M. R., Jeftovic, M., Pusica, S., Stojanovic, B., Duisin, D., Vujovic, S., … Djordjevic, M. L. (2018). Gender Dysphoria: Bioethical Aspects of Medical Treatment. BioMed research international, 2018, 9652305. doi:10.1155/2018/9652305https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6020665/
Marchiano, L. (2017). Outbreak: On transgender teens and psychic epidemics, psychological perspectives, 60:3, 345-366, DOI: 10.1080/00332925.2017.1350804 https://www.tandfonline.com/doi/pdf/10.1080/00332925.2017.1350804