Gender Identity Disorders Among Young People in Germany: Prevalence and Trends, 2013–2022

An Analysis of Nationwide Routine Insurance Data

Despite the fact that gender identity disorders (wording according to ICD-10; ICD-11: gender incongruence) have attracted significantly more public and scientific attention in recent years, especially in the context of transsexuality in adolescents (1), quantitative data on this topic are still scarce in Germany.

The aim of this study was to compile initial data on trends in the prevalence of diagnosed gender identity disorders, the stability of these diagnoses over time and psychiatric comorbidities.

Methods

The nationwide billing data of the Associations of Statutory Health Insurance Physicians in Germany pursuant to Section 295 of the German Social Code (SGB, Sozialgesetzbuch) V were analyzed by the Central Research Institute of Ambulatory Health Care in Germany. The prevalence of the as confirmed coded psychiatric ICD-10 diagnosis F64 “gender identity disorders“ (transsexualism [F64.0], dual-role transvestism [F64.1], gender identity disorder of childhood [F64.2], other gender identity disorders [F64.8], gender identity disorder, unspecified [F64.9]) in at least two quarters of a calender year were evaluated for insured persons aged 5 to 24 years for the calendar year period 2013–2022 (approximately 13.4–14.0 million insured persons) and stratified by age and sex (male/female). In a sensitivity analysis, the ICD-10 diagnosis F66 (psychological and behavioral disorders associated with sexual development and orientation) was also included.

Additionally, in cases of confirmed F64 diagnosis (M1Q), the most common psychiatric comorbidities (according to [2]) were stratified by sex for 2022 in a cross-sectional analysis and the persistence of this diagnosis until 2022 was evaluated for persons who were 5 to 24 years old in calendar year 2017 (longitudinal cohort).

Results

In the period 2013–2022, the prevalence of as confirmed coded F64 diagnoses among insured persons aged 5 to 24 years increased from 22.5/100 000 to 175.7/100 000 (M1Q) and from 15.2/100 000 (M2Q) to 132.6/100 000, respectively. The prevalence of the diagnose F64.0 was fairly constant (range: 70.2% to 78.5%). At the same time, the prevalence of F66 diagnoses declined from 216.7/100 000 to 73.7/100 000 (M1Q) and from 37/100 000 to 19.4/100 000 (M2Q), respectively. Looking at the two diagnoses (F64/F66) in conjunction, a clear increase in prevalence is noted when the M2Q criterion is applied. Applying M2Q, the prevalence increases from 51.9/100 000 to 149.8/100 000, while in M1Q hardly any changes are observed (compare Figure 1).

Figure 1

Prevalence of F64 and F66 outpatient diagnoses coded as confirmed in at least one quarter (M1Q) or at least two quarters (M2Q) per one calendar year among persons with statutory health insurance aged 5–24 years in the period 2013–2022 (Insured persons with a corresponding diagnosis can be considered in several calendar years.)

In almost all years, the highest prevalence of F64 diagnoses (M1Q) was noted among female adolescents in the age group 15 to 19 years (2022: 452.6/100 000, Figure 2). This finding was also observed for F66 (2022: 191.5/100 000).

Figure 2

Prevalence of F64 outpatient diagnoses coded as confirmed in at least one quarter (M1Q) per calendar year among persons with statutory health insurance aged 5–24 years in the period 2013–2022, by gender and age groups. yrs, years; M, male; F, female

In 72.4% of the persons with an F64 diagnosis in 2022 (n = 24 624), at least one additional psychiatric diagnosis was coded (males: 67.3%; females: 75.6%). The most common diagnoses were depressive disorders (males: 49.3%, females: 57.5%), anxiety disorders (23.5%/34.0%), emotionally unstable personality disorder of the borderline type (12.1%/17.6%), attention-deficit/hyperactivity disorders (12.7%/12.6%), and post-traumatic stress disorders (9.9%/13.6%)..

In the longitudinal cohort (n = 7885, 47.1% in the age group 20–24 years; 37.7% male), only 36.4% still had a confirmed F64 diagnosis after five years and diagnosis persistence was below 50% in all age groups (range 27.3% [15–19-year-old females] to 49.7% [20–24-year-old males]).

Discussion

Our study found an 8-fold increase in the prevalence of F64 diagnoses over a 10-year period in insured persons aged 5–24 years. A US study evaluating secondary data for the period 2017–2021 found a 2.8-fold increase in the diagnosis “gender dysphoria”, corresponding to an increase from about 30/100 000 to 83/100 000 (www.reuters.com/investigates/special-report/usa-transyouth-data/). An international registry data study (TriNetX, 80% US data, 2017–2021) reported an increase in F64 diagnoses among 16-year-olds from 47/100 000 to 479/100 000 (3). Thus, our results lie between the findings of the two studies.

The gender distribution of F64 diagnoses in our study (pre-pubertal male preponderance, female preponderance from puberty, convergence in young adulthood) is largely consistent with the findings of Sun et al. (3). The age peaks (15–19 years and 20–24 years in female and male insured persons, respectively) were also identical. The most likely explanation for the decrease in F66 diagnoses (M2Q) is that these were assigned less frequently in favor of F64 diagnoses.

Our data do not allow any conclusions to be drawn about possible causes (for example, actual prevalence increase, increased awareness, decreased stigmatization, improved health care services, overdiagnosis) for the increase in the prevalence of F64 diagnoses. With regard to psychiatric comorbidities, our results are consistent with the literature, at least for depressive disorders (4). The diagnostic persistence over the 5-year follow-up period of less than 50% in all age groups is in line with the literature and presumably reflects the fluidity of the concept of gender identity in childhood and adolescence (5); however, it could also be interpreted as a an indication of the need for a comprehensive, standardized diagnostic procedure (www.cass.independent-review.uk/publications/final-report).

The strengths of our study are the complete collection of outpatient billing data from all persons with statutory health insurance as well as the long observation period. The sensitivity analyses confirm the robustness of trends in F64 diagnoses; even when the M1Q criterion is applied, prevalence is probably underestimated due to the lack of data from psychiatric outpatient clinics. A limitation is a minor ambiguity in the information on gender (in 2022 among approx. 0.3% of the insured persons: “unknown“/”undetermined”/”diverse”). In addition, it was not possible to verify the clinical validity of the coded diagnoses; for this reason, the broad diagnostic category F64/F66 was analyzed.

There is a need for further research into what causes the low diagnostic persistence and the observed increase in prevalence. In the meantime, diagnostic stability and the high prevalence of concomitant mental disorders should be taken into account in the recommendations on the initiation of gender reassignment treatment in adolescence.

Christian J. Bachmann, Yulia Golub, Jakob Holstiege, Falk Hoffmann

Acknowledgement
The authors would like to thank the Central Research Institute of Ambulatory Health Care in Germany, Berlin, for providing the data.

Conflict of interest statement
The authors declare that no conflict of interest exists.

Manuscript received on 17 January 2024, revised version accepted on 2 May 2024.

Cite this as:
Bachmann CJ, Golub Y, Holstiege J, Hoffmann F: Gender identity disorders among young people in Germany: prevalence and trends, 2013–2022. An analysis of nationwide routine insurance data. Dtsch Arztebl Int 2024; 121: 370–1. DOI: 10.3238/arztebl.m2024.0098

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