Gender Dysphoria, Children, And Moral Panics

What new data from the UK shows about trans children

Photo by Kyle on Unsplash

It’s been a year since the Cass review into gender clinics for children in the UK came out. I wrote about the review last year in depth, noting both the few strengths of the document as well as the many weaknesses. If you’re interested in a summary of why the Cass review is not a great document to base any sort of clinical decision-making on, I recommend having a read of those pieces:

There is now an addendum to the story. 9 months after the main review came out, York university has now formally published their epidemiological study looking at trans youth in the UK. This was relegated to an appendix in the original review, and barely mentioned in the document.

Shockingly - but, at this point, unsurprisingly - the new paper from York seems to contradict quite a few of the theories that the Cass review puts forward.

Let’s look at the data.

The Study

Before we dive into the numbers, there’s some important background. Over the last 15 years, the number of children who were referred to UK gender clinics rose quite a bit. This was one of the big reasons that the Cass review was first started - there was some question over what was causing this increase. The Cass review argued that societal acceptance of trans people could not possibly have caused it, and then argued that a range of things were more likely to be the cause.

In particular, the review argued that there were probably more trans kids due to “broader mental health challenges”. The review then suggested that you could reduce the number of trans children by treating mental health issues such as depression or anxiety, which implies strongly that these issues are directly causing children to become transgender:

“The association is likely to be complex and bidirectional - that is, in some individuals, preceding mental ill health (such as anxiety, depression, OCD, eating disorders), may result in uncertainty around gender identity and therefore contribute to a presentation of gender related distress. In such circumstances, treating the mental health disorder and strengthening an individual’s sense of self may help to address some issues relating to gender identity.” - Cass review, page 119. Bolding added for emphasis.

To support this argument, the review used data from York University, who were contracted to provide epidemiological and scientific assistance to the review, showing that the rate of diagnosed gender dysphoria in kids had increased substantially between 2009-2021. The York data also showed that a high proportion of the kids with gender dysphoria in the UK also had co-occurring mental health conditions, which the Cass review argued was supported by data from other countries:

“The systematic review (Taylor et al: Patient characteristics) documented the rapid increase in referrals across many countries and concluded “These children show higher than expected levels of ASD, ADHD, anxiety, depression, eating disorders, suicidality, selfharm, and ACEs. Agreement on the core characteristics data to be collected at referral/ assessment would help to ensure studies measure key outcomes and enable services to develop to meet the needs of these children. Services need to assess and respond to any co-occurring needs and complexities”.” - Cass review, page 97.

In the review itself, the York data was relegated to Appendix 5. But this data has just been published in the journal Archives of Disease in Childhood. The final paper contradicts the Cass review in rather startling ways.

The authors looked at the CPRD database, which is a dataset of 13 million patients seen in primary care practices across the UK. While it’s not perfectly representative of the UK, it does cover around 1/5 of the population and is therefore useful for tracking important clinical diagnoses.

The dataset is also limited in that it only includes routine clinical data. So, for example, you can see in the dataset everyone who has had a doctor diagnosis of depression, but that doesn’t necessarily tell you everyone who is depressed. Many depressed people never get diagnosed, while others are diagnosed but their diagnosis is never recorded.

In this study, the researchers looked at every person aged <18 years who had a diagnosis of gender dysphoria entered into their clinical record between 2011 and 2021. They also compared this group to two controls - kids with a diagnosis of autism spectrum disorder, and kids with a diagnosis of an eating disorder - who were matched by the area where they lived and their age.

The findings are quite interesting. The incidence of diagnoses of gender dysphoria grew quite a bit between 2011 and 2021. Specifically, the rate went from 0.001% up to 0.04%. That’s an increase from around 1 in 100,000 all the way up to 44 in 100,000 kids. For some context, a disease is generally considered to be “rare” if fewer than 50 in 100,000 people suffer from it. The prevalence went from 0.002% up to 0.08%.

Now, we know that this is a limited data source. It doesn’t tell us how many people actually have gender dysphoria, it just tells us how many kids were recorded in clinical systems as having this diagnosis. We know that around 1% of kids in the UK report being transgender, which is far above the rate that this study found for diagnoses of gender dysphoria.

But this also strongly contradicts one of the primary arguments of the Cass review. The review argued that the number of trans kids had exponentially increased, and implied that it was still skyrocketing. While the relative change was large - around 40 times increase over a decade - the absolute increase was minuscule.

The next major finding of this study was that the rate of anxiety was almost identical between the gender dysphoria cohort and the matched controls, and the rate of diagnosed depression was very similar for kids with eating disorders but not those with autism. This contradicts a key argument from the Cass review. The belief in the review is that there was something exceptional about trans children, who were all of a sudden presenting with increased mental health difficulties, and that this meant that the mental health issues were causing gender dysphoria.

Instead, we can see that numerous different groups of kids saw increases in anxiety and depression diagnoses in this time period. This means that there is almost certainly a third factor - probably changes in diagnosis and treatment for anxiety and depression - that explains the increase in both trans and cis kids during this time period.

Pictured: Rates of anxiety in this epidemiological study.

Another key pillar of the Cass review was that the gender services in the UK had gone crazy with medications, and were giving them in a problematic fashion. The review describes the gender service’s actions as a “departure from normal clinical practice”.

However, the York data flatly contradicts this argument. Of the 3,782 children with a diagnosis of gender dysphoria in this dataset, 176 were ever prescribed puberty blockers and 302 ever got hormones. Given the rules about prescribing hormones at the time, that means that <10% of kids in this massive dataset with gender dysphoria ever had a recorded prescription. The authors acknowledge that this could be an underestimate, because the dataset is based on primary care and may not always capture specialist prescriptions, but it’s still a remarkably low number.

It also tracks with the other data that the Cass review identified. We know from the review that 27% of children attending the gender clinics were ever referred for endocrine services. But not all children diagnosed with dysphoria made it to the gender clinics, and not all kids referred to endocrine got medications. So it seems reasonable to say that <10% of kids with gender dysphoria in the UK were likely prescribed puberty blockers or hormones from 2011-2021.

Moral Panics

It’s impossible to square this epidemiological data with the severe criticism in the Cass review. It seems that it was incredibly rare for a child to be diagnosed with dysphoria and ever actually access medications. Much of the review - and certainly the main recommendations - focused on medications, but these were only ever an issue for a small minority of an already tiny group.

The headlines surrounding this study show just how bizarre the moral panic has been. Media everywhere has focused on the “50 times” increase, because it sounds scary, but mostly ignored the “fewer diagnoses than a rare disease” part of the equation.

In fact, this new data from York completely undermines much of the Cass review and the moral panic spurring the document. There are more children overdosed accidentally by the NHS each year than prescribed hormones or puberty blockers, but there are rarely headlines about a child being hospitalized because their doctor accidentally gave them 5x the recommended dose of an anticonvulsant.

We should care about all children’s health, of course. But it’s astonishing how much attention is paid to possible unproven harms for a very small group of children vs proven harms for a much larger cohort.

In addition, medication prescribing peaked in 2017 and was declining at the time of the Cass review’s publication. Children with gender dysphoria did not see an unexpected rise in anxiety and depression as the review claimed based on limited data from overseas. While rates of dysphoria did increase, they remained incredibly low overall, and had plateaued prior to the Cass review coming out. Trans kids were clearly already getting treatment for their mental health conditions, so it’s very unlikely that these mental health conditions were causing kids to become trans. Etc, etc, etc.

This new data doesn’t change all that much. As I wrote previously:

What we can say with some certainty is that the most impactful review of gender services for children was seriously, perhaps irredeemably, flawed. The document made numerous basic errors, cited conversion therapy in a positive way, and somehow concluded that the only intervention with no evidence whatsoever behind it was the best option for transgender children.

The new study just seems like more data that does not support the main findings of the review. As with most such information, it was ignored. Depressing, but no longer surprising for the incredibly flawed Cass review.