I have recently read a fascinating new paper, via a Mail on Sunday report, about the growing number of children presenting as transgender to gender clinics. It raises all sorts of questions, and deserves to be read widely and carefully. The paper, published in the Journal of the American Medical Association, can be found – unlike a lot of similar work, for free – here.

Among its seven authors are two staff from the Gender Identity Development Service (GIDS) in London, the main NHS clinic for children with gender identity issues, including the service’s head, Polly Carmichael. The other authors include clinicians in Australia and the Netherlands, and elsewhere.

The paper is titled ‘Association of Media Coverage of Transgender and Gender Diverse Issues With Rates of Referral of Transgender Children and Adolescents to Specialist Gender Clinics in the UK and Australia’ and largely – but not entirely – considers the possible relationship between rising referral numbers and increased media coverage of transgender issues.

It concludes that the rise in child referrals to gender clinics has taken place at the same time as a rise in media coverage of gender issues. It doesn’t claim to have identified causation, but the authors do offer anecdotal ratification, noting that their own experience with transgender and gender diverse (TGD) children suggests that at least some of them have been prompted to come forward after seeing or hearing trans issues raised in the media:

In this study, we observed evidence of an association between TGD-related media stories and referrals to 2 independent pediatric gender services on opposite sides of the world. Although our data do not provide evidence of causation, the results are nonetheless consistent with our own clinical experiences in which TGD patients commonly identify the media as a precipitant for them to seek clinical assistance.

Now, I don’t challenge the scholarship of the authors, but I do think there are some things missing from their paper. First, the paper doesn’t seem to give much weight, if any, to the idea that causation could just run the other way here: maybe the media are writing about transgender issues more because more children are calling themselves trans?

I don’t doubt that, as the authors say, the growing visibility of trans people in the media (the paper talks about Caitlyn Jenner and TV programmes such as Orange is the New Black) is associated with a wider social climate where some people might feel gender-change is a mundane thing to be casually discussed with others, including doctors.

The paper says:

‘… it is likely that TGD-related media has improved the recognition and acceptance of gender diversity in wider society, and this may have helped to create an environment that fosters referrals. For example, the increasing media portrayal of TGD individuals not only in real life (eg, Caitlyn Jenner and Chelsea Manning) but also in popular fiction (eg, in television shows, such as Transparent and Orange Is the New Black) is likely to have helped not only create an incremental shift in public awareness but also normalize gender diversity.’

But that needs to be dissected a little more. The rise in gender nonconforming kids is, as the paper notes, largely unexplained. (‘The underlying reasons for this increase are of great interest, but there is a lack of evidence to explain it.’) Within that broad rise has been a very steep increase in the number of girls – or ‘children assigned female at birth’, if you prefer, which I don’t – presenting at gender clinics. Again, the authors are candid enough to say that the reasons for this are ‘entirely unclear’.

That being so, it’s a shame the authors didn’t pursue their speculation about media images a bit further. Caitlyn Jenner was ‘assigned male at birth’. So was Chelsea Manning. So was Laverne Cox, the transwoman star of Orange is the New Black. The television show Transparent, meanwhile, shows Jeffrey Tambor acting the role of Maura, a transwoman who transitions late in life. Jenner is 70. Cox is 48. Tambor is 76.

Are media depictions of male-to-female transition among people of such ages really a significant factor in the decisions of adolescent girls who say they are transgender? Given that the TGD caseload is heavily skewed towards young people who were born female, what do they make of a media culture that so often focuses on older people who were born male?

I suppose it’s possible that significant numbers of pre-teen girls are logging on to Amazon Prime to watch 76-year-old Tambor pretend to be a man who says he’s a woman and thinking ‘Gosh, I must be trans too’. By the same token, I suppose I should consider the possibility that such children are subscribing to The Spectator and reading the articles we’ve written about gender issues and deciding to head to the GP looking for a GIDS referral.

I can’t help but wonder if the kids who are swelling the GIDS caseload might not just be a bit more likely to get their information about gender from other sources. Maybe they’re looking at some of this new-fangled social media stuff rather than reading newspapers or watching TV? It is an observed fact that children and teenagers today are much more likely to use YouTube than any other outlet.

In the UK, half of ten-year olds now have a smartphone. YouTube is their top source of entertainment. Surely anyone considering the relationship between media use and a medical-social change affecting children should be interested in this?

Here, the learned JAMA paper goes a bit quiet, almost curiously so. Now, to be fair, the paper is reporting an analysis of two data sets: TGD caseloads and incidence of transgender issues being covered in conventional media outlets. The study doesn’t try to consider social media ‘coverage’ of trans issues.

There are some methodological reasons for that: it’s much easier to use Google News to search keywords in big newspapers and news sites than it is to properly measure social media content on a given issue.

But when it comes to discussing the role social media might – or might not – play in rising trans referrals, the paper is oddly coy. Here’s the relevant extract, at length:

‘… we are also mindful that others have speculated that increased media content (specifically via social media) might act as a double-edged sword or a means of social contagion, whereby some individuals erroneously come to believe through exposure to such media that their nonspecific emotional or bodily distress is due to gender dysphoria and being TGD.30,31Here, the implied outcome is that such individuals will then access gender-related medical interventions and eventually come to regret these once they realize that they are in fact not TGD.

‘Historically, rates of regret are very low among patients attending relevant gender services. For example, among almost 4000 patients who attended the VU University Gender Clinic in the Netherlands between 1972 and 2015 and received medical treatment, only approximately 0.5% were identified as having regret, and there was no evidence that regret rates had increased over time.4

‘Nevertheless, as clinicians working in this field, we are highly mindful of the risk of regret throughout the assessment and treatment process, and it will be important to continue not only to provide adequate counselling before such interventions are undertaken but also to observe whether regret rates increase in the face of greater media attention and more referrals.’

There’s a lot going on there, but here’s how I translate those carefully phrased extracts.

Some people do indeed speculate that social media helps create ‘social contagion’ around trans issues. They suggest that some young people, who get most or all of their information from social media, get caught up in a social setting that leads them to present as transgender as a social act, rather than as the expression of something inside them.

Those suggestions are intensely controversial. Some trans advocates get very, very cross about the idea that some trans people are trans as a social act rather than because of their innate gender identity. Any academic even suggesting that social media channels might help create micro-community social norms that pressure pubescent girls to hate their female bodies and opt out of being female is risking online and real-world opprobrium.

A few years ago, Brown University attempted to disown a paper by one of its own staff, Lisa Littman, because it said the parents of some trans children believed that social media exposure was a significant factor in gender change. The paper was eventually reinstated, but when even an Ivy League college can be cowed by criticism over trans issues, it seems reasonable to suggest there may just be a chilling effect at work that can deter research into the issue. (The case of James Caspian in Bath also highlights resistance to research in this area. )

So you can understand why the authors of the JAMA paper might want to tread carefully. First, they are clear that it is ‘others’ (un-named) who speculate about social contagion and social media. Then they offer something that might look like evidence disproving the contagion theory, in that not many people who change gender at gender clinics later say they regret doing it. Here’s their problem: the absence of evidence of regret cannot be taken as proof of anything, beyond the need to do more research on regret and detransition.

The second problem comes quickly afterwards. If the absence of regret disproves the social contagion theory, then evidence of regret would surely support the theory? Note the paper’s admission that there is always a ‘risk’ of regret and – most importantly – the conclusion that gender clinics should watch this carefully because it’s possible that further evidence of regret will emerge as the number of cases grows. The thing that the authors suggest would prove the social contagion theory (regret) could well exist undetected – and be rising.

In other words, the JAMA paper – though it tries very hard to avoid clearly saying so – concedes that social contagion via social media is a possible factor in the rising number of children with gender issues. That possibility strikes me as rather more interesting and important than some slightly shallow observations about TV shows for and about middle-aged adults, and their alleged impact on the gender identity of pre-teen girls. Let’s hope that some serious research will soon be coming on that possibility. <//>