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Distribution from 1990

In the 1990s, care for transgender people was a small specialism in a few centres. At the UK's GIDS, established in 1989, fewer than 10 children a year were seen in the first few years, mostly prepubertal birth-registered males (source). Early outcome studies were small, and the care that developed later grew from this starting point.

A handful of centers, no evidence

Services for children and young people with gender incongruence started in the mid-1970s in Canada and in 1987 in the Netherlands (see the Dutch rollout); GIDS in London was established in 1989 (source). The Tavistock model for minors ended in 2024 when NHS England closed GIDS, after the interim report of the Cass Review (closure of GIDS) (source).

In 1979 Jon Meyer and Donna Reter published a follow-up of 50 applicants for sex reassignment, operated and unoperated (source). According to the student newspaper of Johns Hopkins, Meyer compared 29 operated patients with 21 who were not operated and concluded that the surgery group was no better adjusted to society; Hopkins stopped performing the surgeries in 1979, and other doctors criticised the study as "seriously flawed in its methods and statistics" (source).

Adult men, classical transsexualism

In the early years of GIDS the largest group was prepubertal birth-registered males; early work focused on therapy with children and families, and only a small proportion with persisting gender incongruence were referred for hormone treatment from around age 16 (source). In 1989 Ray Blanchard published his typology of male gender dysphoria (Blanchard typology): in a study of 212 adult male-to-female transsexuals he found that the non-homosexual groups more often reported sexual arousal by the fantasy of being a woman ("autogynephilia") (source).

The Cass Review describes a marked change in the case-mix, from predominantly prepubertal birth-registered males to predominantly peri- or post-pubertal birth-registered females, with no clear explanation (source). Kaltiala et al. (2020) name awareness, availability of care, destigmatisation and social and media influences as possible explanations, but write that the reasons are not known (source). See the spread from 2010 and Littman's ROGD hypothesis.

Methodologically worthless outcome measures

Early outcome studies were small: Bodlund and Kullgren (1996) followed 19 transsexual patients for five years, of whom 68% had improved in at least two areas of functioning and 16% had an unsatisfactory outcome (source). The Cass Review (2024) calls the evidence on medical treatment of young people "remarkably weak" (source); NICE (2020) judged the certainty of the evidence on puberty blockers as very low (source), and the Swedish systematic review (2023, including SBU staff) found the evidence insufficient (source). According to the Cass Review the WPATH 8 guideline overstates the strength of the evidence (see WPATH SOC) (source).

Dhejne et al. (2011) followed all 324 persons who had sex reassignment surgery in Sweden between 1973 and 2003 and compared them with matched controls: overall mortality was higher (adjusted hazard ratio 2.8), particularly death from suicide (19.1), and suicide attempts were more frequent (4.9) (source). The authors concluded that sex reassignment, although alleviating gender dysphoria, may not suffice as treatment, and called for improved psychiatric and somatic care afterwards (source).

Preparation for the pediatric rollout

The 1990s brought no empirical breakthrough, but they did bring infrastructure: specialised clinics and an international network (HBIGDA, later WPATH). The first case report on puberty suppression was published in 1998 by Cohen-Kettenis and van Goozen at Utrecht (source). According to the Cass Review the Dutch protocol was developed in the Netherlands and later adopted in the UK and internationally (source); it was developed for a different group than the adolescents who started presenting from 2014 (source). See the Dutch pediatric rollout from 2000 and the VUmc protocol.

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