A year after moving to Bridge City, Texas, 8-year-old Samuel Kulovitz thought his life couldn’t get any worse. He had made no friends in the swampy oil refinery town and spent most of his time in his family’s mobile home. He missed Florida and playing on the beach there with other children.
But life did get worse. He hit puberty. For Kulovitz, who was assigned female at birth, “growing into being a young woman horrified me,” he said. “I kept crying and crying, and I didn’t know why I didn’t like it.”
Then, at age 11, Kulovitz started venturing onto social media. There, he came across a cosplayer on Tumblr who said he realized he was a transgender boy from the euphoria he felt while dressed as the hero of an online comic. Kulovitz was transfixed. “I kept asking myself, ‘Why do you want to look like him?’” he told Reuters. In the online community where Kulovitz spent more and more time, he adopted the pronouns “he” and “him,” and he liked it.
When his mother learned of his transgender identity, she was supportive and enrolled him in therapy. He was diagnosed at age 12 with gender dysphoria, the distress that comes from identifying as a gender different from the one assigned at birth.
Two and a half years later, Kulovitz started on the hormone testosterone. He was thrilled as he grew facial and chest hair, his voice dropped, and his menstrual periods stopped.
Still, his breasts were a constant source of distress, and his body ached from wearing a chest binder. “I always thought, ‘I wish I could get rid of them,’ “ Kulovitz said.
One day during his junior year of high school, Kulovitz, then 16, was scrolling on his phone when the TikTok account of a Miami surgeon who offered to “yeet the teets” of young transgender people popped up. In videos with hip-hop music playing in the background, Dr Sidhbh Gallagher provided detailed information about top surgery to remove or modify breasts and displayed photos of her satisfied gender-diverse patients, most of them young people, with shirts off to show the results of the doctor’s work. “Come to Miami to see me and the rest of the De Titty Committee,” she said in one of the videos.
Six months later, in June 2021, Kulovitz was in Miami with his mother, who gave consent for her son’s surgery and paid $10,000 out of pocket for it. He also had the letters of support Gallagher required from his therapist and doctor. When Kulovitz woke up after the procedure, “I felt euphoric,” he said. “I finally felt right in my body.”
A question of influence
Thousands of children who, like Kulovitz, were assigned female at birth have sought gender-affirming care in recent years. And for reasons not well-understood, they significantly outnumber those assigned male at birth who seek treatment.
As Reuters reported in October, a growing number of the children receiving care at the 100-plus gender clinics across the United States are opting for medical interventions – puberty-blocking drugs, hormones and, less often, surgery. And they are doing so even though strong scientific evidence of the long-term safety and efficacy of these treatments for children is scant.
That has led to a split among gender-care specialists: those who urge caution to ensure that only adolescents deemed well-suited to treatment after thorough evaluation receive it, and those who believe that delays in treatment unnecessarily prolong a child’s distress and put them at risk of self-harm.
The outsized proportion of adolescents seeking treatment to transition from female to male has sparked parallel concerns. Professionals in the gender-care community agree that treatment of all transgender children should be supportive and affirming. The question, for some, is whether peer groups and online media may be influencing some of these patients to pursue medical transition, with potentially irreversible side effects, at a time in their lives when their identities are often in flux.
Corey Basch, a professor of public health at William Paterson University in New Jersey who researches health communication and teens’ use of social media, said she fears that some adolescents are susceptible to making faulty self-diagnoses without adequate input from medical professionals. “Teens are so incredibly vulnerable to information overload and being pushed in one direction,” Basch said. “They could be lacking the analytical skills to question who is giving this advice and if their advice is valid.”
Adolescents assigned female at birth initiate transgender care 2.5 to 7.1 times more frequently than those assigned male at birth, according to the World Professional Association for Transgender Health (WPATH), a 4,000-member organization of medical, legal, academic and other professionals. Several clinics in the United States told Reuters that among their patients, the ratio was nearly 2-to-1, and similar phenomena have been documented in Europe, Canada and Australia.
Not all of these patients receive medical treatment. Their gender-affirming care may entail adopting a name and pronouns aligned with their gender identity. It may include counseling and therapy. But an increasing number are opting to take hormones and have top surgery.
In October, researchers at Vanderbilt University School of Medicine published a paper showing a 389% increase in gender-affirming chest surgeries performed nationally from 2016 to 2019 on patients under age 18. The total of 1,130 procedures during the period, nearly all of them for chest masculinization, represents a weighted estimate based on records from more than 2,000 U.S. medical facilities. Likewise, at least 776 chest masculinization surgeries were performed on patients ages 13 to 17 with a gender dysphoria diagnosis over the past three years, according to U.S. insurance claims analyzed for Reuters by health technology company Komodo Health. This is probably an undercount because it does not include procedures paid for out of pocket.
The predominance of patients assigned female at birth is a reversal from the past. For years, when very few minors sought gender care, those assigned male at birth accounted for the majority. But about 15 years ago, that began to change as care became more accessible and the overall number of patients started climbing, according to studies and interviews with gender-care specialists.
For example, at Amsterdam University Medical Center’s gender clinic, a pioneer in adolescent gender care, the proportions flipped. From 1989 to 2005, 59% of its adolescent patients were assigned male at birth, the Dutch clinic reported in a 2015 study published in the Journal of Sexual Medicine. Since 2016, about 75% of the clinic’s patients have been youths who were assigned female at birth.