Evolution and trends in referrals to a specialist gender identity unit in Spain over 10 years (2012-2021)

Abstract

Background International studies have reported an increase in referrals to gender identity units, a shift in the assigned sex ratio of adolescents, a decrease in the age at first visit, and a growing presence of individuals with nonbinary gender identities. Aim To investigate whether these trends are present in a Spanish sample of individuals referred to a gender identity unit over the last 10 years. Methods We conducted a retrospective chart review of 913 consecutive referrals to a gender identity unit between 2012 and 2021 and retrieved information regarding sex assigned at birth, age at first visit, and expressed gender identity. We stratified the patients into 5 age categories: children (<12 years), adolescents (12-17 years), young adults (18-25 years), adults (26-45 years), and older adults (>45 years). The data were analyzed via descriptive and regression analyses. Outcomes Outcomes included the number of annual referrals, age at first visit, assigned sex ratio, and individuals with nonbinary gender identities. Results The number of referrals increased 10-fold, from 18 in 2012 to 189 in 2021. The rates of increase over time were significantly more pronounced for adolescents and young adults and significantly greater for those assigned female at birth (AFAB). The age of referrals at first visit decreased, and AFAB individuals were, on average, younger than individuals assigned male at birth. The assigned sex ratio favored AFAB patients among adolescents (2.4:1) and young adults (1.75:1). Logistic regression showed that the odds of a new referral being AFAB increased by 9% per calendar year and that adolescent and young adult new referrals were significantly more likely to be AFAB. There were 21 referrals of nonbinary individuals starting in 2017, making up 6.4% of applications in 2021 and 2.9% during the last 5 years. Clinical Implications The evolution and trends observed in this study highlight the need for expanded resources, competent care, and careful reflection about implications for best practice. Strengths and Limitations This investigation involves a large sample of patients and is the first in our country to include people of all ages. However, the findings might not be generalizable to other gender identity units or the broader population of gender-diverse individuals. Conclusion Overall, our findings were consistent with previous international reports. We observed a marked increase in referrals, particularly among AFAB adolescents and young adults, a decreased age at first visit, and a growing presence of nonbinary individuals.

Demographics of referrals to a specialist gender identity service in the UK between 2017 and 2020

“…The mean age of referrals made in 2019 were marginally younger compared to other referral years, with oldest age of referral noted as 2018, only a .2 year mean age difference. This indicates a general consistency in referral age across the years assessed and matches international data on referral age to services (Expósito-Campos et al, 2023). We also note that that there was a lower rate of referrals made in 2020 which is likely owing to the imposed lockdown in the UK due to the COVID-19 pandemic.…”

Patterns of gender identity data within electronic health record databases can be used as a tool for identifying and estimating the prevalence of gender-expansive people

“…We observed a bias toward AFAB in the gender-expansive population between 12 and 29 years old, especially in the nonbinary population, a trend noted in other published studies in clinical settings. 23 , 38–40 Interestingly, survey data with larger sample sizes have not shown this bias. 11 , 40 There are a number of potential factors that may influence disclosure of gender-expansive identity by adolescents and young adults in a clinical setting including referral bias, social and peer acceptance, and concerns with medical privacy (especially for adolescent patients related to parent/guardian access to medical information).…”

“… 11 , 40 There are a number of potential factors that may influence disclosure of gender-expansive identity by adolescents and young adults in a clinical setting including referral bias, social and peer acceptance, and concerns with medical privacy (especially for adolescent patients related to parent/guardian access to medical information). 11 , 38 , 39 , 41 In contrast, adolescents and young adults may report GIs more openly in surveys that preserve anonymity. 11 The adolescent and young adult populations at our institution also account for nearly all gender-expansive identities not included in the SOGI field choices within the EHR (eg, agender, demiboy, gender queer, transfeminine), illustrating age-related variation in adoption of specific terms other than transgender or nonbinary to identify GI.…”

Adolescent gender dysphoria management: position paper from the Italian Academy of Pediatrics, the Italian Society of Pediatrics, the Italian Society for Pediatric Endocrinology and Diabetes, the Italian Society of Adolescent Medicine and the Italian Society of Child and Adolescent Neuropsychiatry

“…Notably, not all individuals with GI characteristics in childhood necessarily exhibit symptoms of GD. A notable shift in the sex ratio of clinically referred adolescents has accompanied the increase in referrals, with more assigned female at birth (AFAB) young people now seeking help compared to assigned male at birth (AMAB) [ 5 ].…”