Disagreement about the permanence of gender-related distress experienced during adolescence is at the heart of the debate about the practice of youth gender transition. Those concerned about the practice point out that the endocrine and surgical interventions used to treat gender-related distress have lifelong, irreversible effects, and therefore should be delayed until maturity when there is more certainty that the trans identity will endure. The advocates of medical gender-affirmation for youth assert that gender dysphoria presenting in adolescence is usually permanent, and therefore the permanent nature of the treatments is not a concern.

A new study (now available in English) from Germany poses a formidable challenge to the presumption of permanence of gender dysphoria in adolescents and young adults. German insurance data, containing medical claims for about 14 million insured persons aged 5–24, indicate that over 60% of young people diagnosed with "Gender Identity Disorder" (F64) no longer have the diagnosis 5 years later, indicating low diagnostic stability.

The study's notable findings are highlighted below:

• There has been an overall 8-fold increase in the prevalence of gender-identity-related diagnoses (F64), overrepresented among adolescent females over the last decade. Like other international data, the German data reveal a marked increase in gender-identity-related diagnoses (F64) in youth in the past decade.  Adolescent females had the highest prevalence (452.2/100,000) and have experienced the sharpest increase (12-fold, from 37.9/100,000 in 2013).

• Young gender dysphoric adults (aged 20-24) represent a key group with similar dynamics to adolescents. While most focus to date has been on older adolescents, the German data show that there has also been a sharp increase in gender identity diagnoses in young adults. In 2022, the reported prevalence for the three highest-prevalence groups was:
• Ages 15–19, female: 452.6/100,000 (1 in 221)
• Ages 20–24, male: 306.4/100,000 (1 in 326)
• Ages 20–24, female: 301.5/100,000 (1 in 331)

Overall, the gender-related diagnoses increased 11-fold in older adolescents, and 7-fold for young adults.*

• Youth diagnosed with gender dysphoria suffer from a high rate of mental health comorbidities.  Over 70% of young people diagnosed with gender dysphoria had at least one other psychiatric diagnosis (67% of males and 76% of females). In order of decreasing frequency, comorbid diagnoses were depressive disorders, anxiety disorders, borderline personality disorders, attention deficit/hyperactivity disorder, and post-traumatic stress disorders.
• For most young people, the gender-identity related diagnosis (F64) does not persist after 5 years. After 5 years, only 36.4% retained the gender identity-related diagnosis on their records. Adolescent females aged 15–19 had the lowest persistence rate (27.3%), while young males aged 20–24 had the highest persistence rate (49.7%). While other explanations for the finding of low diagnostic stability of gender-related diagnoses in youth are possible  (e.g., delaying medical interventions until an older age, using creative coding strategies that avoid using the F64 gender identity diagnosis), the sheer magnitude of non-persistence of the diagnosis (over 60% overall, and over 70% in young females) has significant implications for treatment.
• Diagnoses relating to gender identity are supplanting diagnoses relating to sexual difficulties. The German analysis shows that the sharp increase in gender-identity related diagnoses (F64) has been offset by a commensurate drop in the sexual development diagnoses (F66). The F66 diagnostic category includes “sexual maturation disorder” and “egodystonic sexual orientation.” **  When the two groups of diagnoses (F66 and F64) are combined, the prevalence of diagnosed “sexual-and-gender-related difficulties” remains nearly unchanged over the last decade in Germany. This suggests that conditions that were previously understood as sexual development struggles (F66) may have been reconceptualized as gender-identity related problems (F64), at least in Germany.

The authors conclude that the sharp increases in prevalence of gender-related diagnoses, high rates of co-occurring mental health conditions, and low diagnostic stability of the diagnosis merit serious consideration before the initiation of gender transition interventions in young people. 

SEGM Takeaways

The proponents of youth transition do not recommend any medical or surgical interventions for younger children, because it has been well-established that gender dysphoria/incongruence presenting in childhood typically self-resolves. However, these same gender clinicians assert that the situation changes drastically once gender dysphoria is present in adolescence, insisting that such adolescents will be "trans adults."  This notion is at the heart of the ethical justification of medically intervening with adolescents with a treatment that has many irreversible consequences. The paucity of data about contemporary gender-dysphoric adolescents has created an information vacuum that has been filled with unsupported claims that “adolescents do not desist.” 

The finding of low diagnostic stability of gender identity diagnoses in contemporary youth is consistent with several recent studies showing a high rate of resolution of gender non-contentedness, and significant rates of medical detransition (10-30%). A recent BMJ publication concluded, “GD [gender dysphoria] is not a permanent diagnosis.”

Another finding in the study deserves careful consideration. It appears that young people currently diagnosed as having “gender identity” problems (F64), may have been previously diagnosed as having  “sexual maturation disorder” and “egodystonic sexual orientation” (F66 diagnosis). **  This raises important questions about the accuracy of current diagnostic procedures for young people with gender distress, and the possibility that youth who were previously understood as going through developmental struggles related to their emerging sexuality, are currently viewed as "transgender." This further points to the need to reconsider the clinical significance of the F64 “gender identity” diagnosis. Administering irreversible endocrine and surgical interventions based on a diagnosis of such poor diagnostic stability is problematic, given the lifelong, irreversible nature of the "gender-affirming" interventions and their lifetime medical burden.

*Based on additional data obtained in the correspondence with the authors.

**The ICD-11, which came into effect in 2022 but is still in the process of implementation, has eliminated the F66 diagnosis; however it appears that the diagnosis was still in use during the reporting period in the study.