Gays Against Groomers Public Comment on the Proposed Changes to Title IX Regulations

Earlier today, we submitted our official public comment on the proposed changes to Title IX regulations, which aims to include legal protection based on "gender identity." The implications from them will not only put children's wellbeing and safety in danger, but erase all sex-based rights as well.

---

Running Head: GAYS AGAINST GROOMERS [Docket ID ED–2021–OCR–0166] Title IX Public Comment [Docket ID ED–2021–OCR–0166] Michael Costa, Gays Against Groomers

Introduction: Gays Against Groomers is a coalition of gay people who oppose the recent trend of indoctrinating, sexualizing and medicalizing children under the guise of “LGBTQIA+.” Our community that once preached love and acceptance of others has been hijacked by radical activists who are now pushing extreme concepts onto society, specifically targeting children in recent years. The overwhelming majority of gay people are against what the community has transformed into, and we do not accept the political movement pushing their agenda in our name. Gays Against Groomers directly opposes the sexualization and indoctrination of children. This includes drag queen story hours, drag shows involving children, the transitioning and medicalization of minors, and gender theory being taught in the classroom. The Biden Administration’s proposed Title IX amendments are anti-gay and our coalition does not consent to putting this into law.

Concern 1: Sex and Gender Sex and gender need to be properly defined in the law. Sex is biological and refers to male or female. It is determined by gonadal and chromosomal biochemistry. Typically, 99.98% of the time, the chromosomes are karyotyped as XX or XY. There are variations to this for .02% of humans (Sax, 2022). For instance, someone may have chromosomes XXX, XYY, X, XYX, etc. These are called “congenital conditions of sexual development”, which is also described as “intersex” and “sex characteristics” in the proposed Title IX updates. Upon fertilization, only the X chromosomes are active for the first month and the fetus is set to develop as “female”. During the second month of pregnancy, the Y-linked SRY gene is activated and the fetus will begin to develop as male. If a Y chromosome is not present, then it continues developing as a female.

Sex (male and female) are determined by the presence of absence of the Y chromosome. Humans with karyotypes containing a Y chromosome, such as XY, XYY (Jacob’s Syndrome), XYX (Klinefelter Syndrome), “49, XXXXY”, XXYY Syndrome, etc. are all male. People with karyotypes XX, XXX ( Triple X Syndrome), X (Turner Syndrome), XXXX (Tetrasomy X), etc. are all female. While intersex conditions do exist and should have protection under the law, every human is male or female (Bhargava et al., 2021) Sexual orientation is completely based on maleness and femaleness. The three sexual orientations are heterosexual, homosexual, and bisexual.

Sexual orientation is determined through genetic, immunological, endocrinological, epigenetic, and hormonal interactions in the womb and is determined before birth. There is no significant data showing a relationship between sexual orientation and postnatal socialization. Homosexuality can develop a few different ways and these prenatal mechanisms can be identified in an individual’s brain anatomy, salivary steroidal composition, texture on the fingertips, finger length, and facial morphology (Caspers et al., 2010). A gay person who developed under the immunological model via Y-linked antibodies (NLGN4Y) does not have the same facial morphology patters, sex behavior, or gender conformity as a gay person who developed via epigenetics or amniotic hormone composition. Sexual orientation is anatomically determined by the third interstitial nucleus of the anterior hypothalamus (INH-3) and the suprachiasmatic nucleus (SCN), which determine whether an individual’s hypothalmic region is activated by male pheremones or female pheremones. Sexual orientation is completely sex-based and has nothing to do with gender.

Gender, on the other hand, has an array of definitions that have changed over time. At first, it was synonymous with sex. It also was defined according to gendered language, on the basis of how adjectives, verbs, and nouns differ depending on whether the subject is male or female. Gender has been defined as “masculine or feminine”. The social constructionist view of gender was first started by second-wave feminist academic scholars and was later used during the Women’s Liberation Movement in the United States. Gender was separated from sex and it referred to socially constructed roles and stereotypes which are placed upon women via the patriarchy (on the basis of being female). In this use of the word, gender is what prevented women from having the right to vote, being forced to wear uncomfortable clothing, become housewives instead of doctors, and forced them to act “ladylike”. This branch of academic feminism sought to abolish gender and liberate women from patriarchal notions of femaleness, giving them a way to describe how male supremacy has affected women for centuries “on the basis of sex”. In the 1990s, the Butlerian definition of gender was created to describe “Gender Performativity”, stating that gender is a social performance in which you signal your gender to others via sex stereotypes like clothing and behavior. Gender was placed on a spectrum and it was determined by one’s “Gender Identity”, a belief that everyone has an internal sense of their gender that is invisible, cannot be measured, ideologically constructed, and independent of sex. Butler claimed that gender was on a spectrum, which is a philosophical outlook that has no material basis in science or material reality whatsoever. There is no clear definition of any of these sex/gender terms in the proposed Title IX amendments and therefore cannot be properly enforced without putting other people’s rights in jeopardy.

Sex (biological), sexual orientation (biobehavioral), and gender-stereotypical (social) interests all intersect when it comes to gay people and cognitive sex. Using the biopsychosocial model, research in the field of cognitive sex examines sex differences in cognitive tasks, personality, partner preferences, sexual behavior, and gender nonconformity (Lippa et al, 2008). Gender is a social construct, but gender-stereotyped behavior and cognition differs among four sex-based classes of individuals: males, females, heterosexuals, and homosexuals. These patterns are cross-cultural and have been observed in neurological research over the past 35 years. Prenatal androgen exposure is related to finger length and recalled childhood gender nonconformity (Swift-Gallant et al., 2022) due to neurohormonal masculinization in-utero. A meta-analysis of sexual orientation and cognitive performance (Xu, Norton, & Rahman, 2017) consisted of 254,231 participants. In cognitive tasks that favor males, like spatial cognition, cognitive and behavioral tasks yielded different effect sizes for homosexual men vs. their heterosexual couterparts. Gay men performed worse on male-favored tasks and more similar to heterosexual women. Homosexual women were also sex-atypical on the male-favored tasks, with results similar to heterosexual men, and scoring higher than heterosexual women and gay men. In cognitive sex studies, gay men and women always have a higher rate of gender nonconformity in childhood and adulthood (Cohen-Bendahan et al., 2005). Handedness is associated with childhood gender nonconformity when measured as a mediating factor, observing extreme left-handedness and extreme right-handedness, which matches the inverted-U curvilinear pattern of neuroendocrinological development (Kishida, & Rahman, 2015). A 2008 study by Lippa, R.A. sampled over 700 participants and found the same patterns for childhood and adult gender nonconformity being much higher for gay men and lesbian women, consistent with the existing literature since the 1990s (Lippa, 2008). Event-Related Potentials on electroencephalography studies show the same results with mental rotation and semantic monitoring tasks (Wegesin, 1998), which have a positive correlation with childhood gender nonconformity. The relationship between adult homosexual orientation and gender nonconformity has been a consistent indicator of homosexual orientation in adulthood (Wallien, 2008b). Therefore, a gender nonconforming child should not be told that they are the opposite sex and socially transition at school without parental knowledge (Carr, 2005). Gender stereotypes are not dependent on sex and there is no way to tell if a child will identify as transgender in adulthood. Labeling a child with a sexual orientation or gender identity is grooming, and it is inappropriate to do this at school.

Concern 2: Sexual Orientation and “Queer Sexuality” In the proposed Title IX changes, replacing “sex” with “gender” means that LGB is conflated with TQIA+. Without a proper definition of ”sex,” meaning male and female, the rights which protect heterosexual and homosexual people will no longer mean anything.

This completely redefines “sexual orientation”. Sexual orientation is based on sex and written into law as such. However, when “Sex” is replaced with “Gender” in the law, then sexual orientation is redefined out of existence. Sexual orientation, which is defined in the law as “Heterosexual, Homosexual, and Bisexual” are terms which are based on maleness and femaleness. Replacing the notion of “male and female” with “Gender Identity” renders the term “sexual orientation” meaningless and will remove the rights protected under it. None of the vocabulary is defined in the new Title IX, and this leaves room for anything to be included under it.

Gays Against Groomers is very thankful that gay people were recently granted legal protection in the workplace. However, the Bostock Decision adding “gender” into our sex-based rights is harmful because “Sexual Orientation” in Title IX is not defined whatsoever. How can homosexual people be protected in law if the law does not provide a definition of “homosexual?” Under the amended Title IX, gay people are conflated with “queer” and no definition of this word is provided, According to the available academic literature, “queer sexuality” includes anything that pushes boundaries or breaks down the sexual barriers which society has already set in place. “Queer Sexuality” can be interperated to include kink, paraphilias, beastiality, pornography, sadomasochism, and would provide protection for sexual fetishists in schools. Autoanthropomorphozoophilia, a paraphilia which involves cartoon animals and dressing up as animals for sexual purposes (in 99% of cases) is not appropriate for children whatsoever. We have received reports from teachers and parents of students discussing this during school hours.

The government wants to pass a law that is harmful to gay people and the majority of us strongly oppose it. Replacing the legal definition of “sexual orientation,” to conflate gay people with fetishists and criminality is an insult. It also does not provide a definition of “transgender” and “cisgender.” The term “cisgender” was coined in the English language in the 1990s by Volkmar Sigusch, a sexologist who openly advocated for child abuse. This is not the type of language one should feel comfortable incorporating into our public education system.

This reinterpretation of the language that gay people use to describe ourselves will make it impossible to describe a global population of people who exist cross-culturally, share a history, biobehavioral reality, and how we love one another. Gay people advocated for the right to love one another, and we still do.

Concern 3: Childhood Gender Variance In the proposed Title IX updates, “sex” is defined as “sex stereotypes, mannerisms, interests, and clothing.” In 2013, a study found “childhood gender variance” to be 8 to 15 times higher for gay adults (Steensma, van der Ende, et al., 2013). Most gay men expressed more stereotypically feminine traits in childhood, including mannerisms, interests, clothing, hobbies, and socializing with girls (Skidmore et al., 2006). This is so common that the concept of “Gender Incongruence” in childhood needed to be completely reevaluated because it was based on masculine/feminine stereotypes (Skidmore et al, 2006) that were not a medical issue – it was just children expressing themselves in ways that did not conform to gender stereotypes placed on male and female people by society (Barlett & Vasey, 2007). A girl who likes to play sports, cut her hair short, or wear pants instead of dresses should never be told that she is “wrong” for doing such things. However, schools are encouraging “tomboys” (Volkom, 2003) to identify as male, which likely leads to medicalization.

The vague definition of “Gender Identity” is “a fluid internal feeling of gender that is constantly changing.” It includes an infinite amount of identities that one can label themselves with. If gender is fluid and constantly changing, then why would children be encouraged to irreversibly alter their bodies permanently? There is no way to tell whether a child’s gender variant behavior will result in them identifying as transgender in adulthood. In the vast majority of these children, that is not the case. Studies show that over 80% of the time, these children just wind up being adult homosexuals (Wallien, 2008a).

When a gender nonconforming child is not socially transitioned, 63.4% of gender dysphoric boys grow up to be gay and bisexual men (Singh, 2012). The majority of children who meet some of the criteria for “early onset gender dysphoria” outgrow their dysphoria and wind up being gay and lesbian adults (Barlett & Vasey, 2006). When a child is socially transitioned before going through puberty, this very often leads to medicalization and these children are likely to be sterilized (Steensma & Cohen-Kettenis, 2011). Social transition is not just a haircut or name change – it is often a direct pathway to puberty blockers (Elhakeem et al., 2019; Pang et al., 2020) and exogenous hormones. Most of these issues resolve with their natural male/female puberty (Steensma et al., 2013). A gender nonconforming child can socially transition at school without the parents knowledge and will most likely result in becoming a permanent patient for the rest of their lives under the proposed updates. These medications (Lee et al., 2020; Vlot et al., 2019) are linked to bone loss (Delgado-Ruiz et al., 2019) and bone density issues (Biggs, 2021).

Studies show that socially transitioning a gender nonconforming child will most likely lead to being sterilized before puberty (Cheng et al., 2019). A 2013 study also found that socially transitioning children is correlated with persistence and medicalization (Steensma et al., 2013). A follow-up study of 139 gender dysphoric boys determined that 88% of them desisted and did not go through with transition and chemical castration. We find it very concerning that the rates of socially transitioning children has drastically increased in recent years, given this scientific information. Professionals in this field are starting to recommend against it. The “Dutch Model,” (de Vries et al., 2012) which is a method currently used to transition children (de Vries et al., 2012), only contains data from a small number of patients who are under the age of 18. The pioneers of this model (Kuyper & Wijsen, 2014) recently warned against social transition because they were seeing very worrisome trends (CM et al., 2018). The attached references provide all the data that we could find, both nationally and internationally (Wiepjes et al., 2015). This involved communication with researchers internationally, data analysis, extensive literature reviews, and countless hours of work. Academics and research scientists in our organization worked very long and hard to put this together, and the cited research contains data from over 200,000 study participants. It is important and needs to be considered before putting this into law. We are possibly facing a huge medical scandal in this country, and the government-controlled schools will be to blame. Socially transitioning a child and hiding it from parents is grooming and abusive.

Concern 4: Detransition There is nothing more homophobic than turning your teenage daughter into a boy, upon finding out that she might be gay or bisexual. Medicine should be evidence-based, especially when it comes to children. Research in this area should be considered (Neave & Weightman, 1999), including the data which suggests that this recent outbreak of female adolescent gender distress is a psychic epidemic. In 2018, a research study examining young adults and teenagers who identify as “transgender” stated that exactly two-thirds (67.8%) of them are in friend groups containing multiple gender dysphoric teenagers who did not have a previous history of gender incongruence in childhood. Nearly 87% of them adopted their transgender identities at the same time (Littman, 2019). The same study confirmed that 37% of these groups consisted mostly of “transgender” teenagers. For such a small demographic of people (Arcelus et al., 2015), these results are shockingly high. Professionals in this area are doubtful that this is an organic phenomenon. We believe that this is the result of grooming. For instance, some schools provide chest binders (Peitzmeier et al., 2021) for teenage girls to flatten their breasts. These binders are very tight (Poteat et al., 2018) and cause lung damage (Cumming, 2016). They are linked to health issues (Peitzmeier, 2016), including chest pain (30%), becoming light-headed (30%), shortness of breath (49%), and back pain (65%). Testosterone use is highly correlated with heart attacks (Alzahrani et al., 2019; Nota et al., 2019) and life-long health issues, including cancer (Baldassarre et al., 2013; Bettocchi et al., 2005; Madseh et al., 2021).

Last year, a study of 237 detransitioners found that the majority of them medicalized their bodies due to homophobia and feeling insecure of their attraction to women (Vandenbussche, E. 2021). Another American detransitioner study (n=100) found similar results (Littman, 2021). 51% of female participants and 45% of male participants medically transitioned because they thought it would result in society treating them better. 52% cited homophobia as the main issue and reason for doing irreversible harm to their bodies. Females who detransitioned were three times more likely to be lesbians. This information suggests that gender transition before adulthood is a new form of conversion therapy. Gender dysphoria will alleviate for 80% of these children when they go through puberty. If puberty seems to be the cure, then it is completely unethical to block their natural puberty from ever occurring.

Concern 5: Suicidal Ideation: Politicians, media, teachers, activists, and lawmakers have been campaigning for child sterilization and queer ideology in schools on the basis of “suicide”. Suicide is a very serious issue and must be reported accurately, based on all of the relevant data. The claim that there is a suicide epidemic of transgender or “LGBTQIA+” youth is a lie. There is no mass-suicide of transgender children and there never has been. This myth is being perpetuated by our elected officials and reporters in order to gaslight the public into accepting their current demands. This myth is repeated by advocacy organizations and even posted on school websites. The Biden Administration is trying to put this into law and shut down any debate, based on the notion that discussing a conflict of rights will be harmful to transgender students. According to the proposed Title IX amendments, one is not allowed to question the fairness and safety of having males compete against females in sports. If a male wants to use a female locker room or bathroom, students are not allowed to object. Pronoun usage is mandatory and any disagreements are considered “sex harassment”, harmful, and might result in transgender people committing suicide. These rules assert that over 40% of LGBTQ+ children are suicidal, which is a false claim (Tanis, 2016). This comes from a survey which encouraged participants to have their friends complete, as well. 40% of the sample were not transgender and most of them do not intend on transitioning. The study was biased, inconclusive, vague, does not provide proof that such a phenomenon exists, and is being misused to further a political goal. In Sweden, data shows that less than 1% of people with gender dysphoria commit suicide. Gays Against Groomers does not approve of the public being told that people like us are suicidal, self-destructive, sensitive to criticism, and in danger of taking our own lives. Also, spreading this false information is harmful to LGBTQ+ people because being told that we are at a high risk for suicide is only going to cause distress (Tiedemann, 2022). Parents have been convinced that their “transgender” child is likely going to commit suicide if they are not injected and sterilized with “puberty blocker” hormone agonists. There are reports of parents objecting to the use of these drugs on their children and subsequently being told that they need to choose between having a “trans child” or a “dead child,” despite there being no evidence of this. Recent studies do not show a significant difference in the rates of suicidal behavior for gender dysphoria in clinical populations. Puberty blockers do not decrease rates of suicidal ideation and show little positive effects on mental health. Children are being groomed into socially transitioning and becoming sterilized before puberty.

Conclusion: The Title IX amendments are extremely anti-gay. The Biden Administration’s proposed law is unacceptable. Gays Against Groomers is a gay rights organization, which mostly consists of the same gay men and women who marched for same-sex marriage. We never pictured the United States creating a law that is riddled with homophobia. This law does not consider the interests of gay people and legally mandates that we follow an ideology that we never consented to. The United States is proposing that we change the laws in such a way that defines homosexuals out of existence. It will cause physical and mental harm to future gay men and women – Today’s generation of children are being transitioned out of their “assigned sex”. It represents everything that gay people fought against.

Gays Against Groomers appreciates the opportunity to leave this commentary. In the United States, we have a long history of the medical industry castrating, pathologizing, medically abusing, and telling us that we need to change ourselves in order to adhere to gender stereotypes because our behavior is “wrong”. No child should ever be encouraged to pursue a different identity or be told that being who they are is wrong. Changing a child’s name, gender marker, appearance, social role, etc. is the opposite of being “affirming.” If we were growing up today, we would have been victims of this ideology and had our lives ruined via sterilization, amputation, shortened life span, physical discomfort, and irreversible physical harm to our bodies. We love being gay adults and would never want to be anything else. Conflating us with queer fetishism in the law is an insult. All members of our coalition highly urge you to consider the opinions of the gay community before mandating an anti-gay law in our name. The gay community is not a monolith whatsoever, but the majority of us agree that this law is unacceptable. It represents everything the gay community has always fought against. It is homophobic, dishonest, unsafe, and will have a horrible impact on us as a minority population. As a gay rights organization, we do not consent to the proposed Title IX amendments. Please reconsider this immediately. Thank you.

References Alzahrani, T., Nguyen, T., Ryan, A., Dwairy, A., McCaffrey, J., Yunus, R., Forgione, J., Krepp, J., Nagy, C., Mazhari, R., & Reiner, J. (2019). Cardiovascular Disease Risk Factors and Myocardial Infarction in the Transgender Population. Circulation: Cardiovascular Quality and Outcomes, 12(4). https://doi.org/10.1161/circoutcomes.119.005597 American Psychiatric Association. Diagnostic and statistical manual of mental disorders (4th edn). Washington, DC: American Psychiatric Association; 1994. Ames, C. (1992). Classrooms: Goals, structures, and student motivation. Journal of Educational Psychology, 84(3), 261–271. APA PsycNet. (n.d.). Psycnet.apa.org. https://psycnet.apa.org/record/1994-01588-001 Arcelus, J., Bouman, W. P., Van Den Noortgate, W., Claes, L., Witcomb, G., & Fernandez-Aranda, F. (2015). Systematic review and meta-analysis of prevalence studies in transsexualism. European Psychiatry, 30(6), 807-815 Ashley, F. (2019). Shifts in Assigned Sex Ratios at Gender Identity Clinics Likely Reflect Changes in Referral Patterns. The Journal of Sexual Medicine, 16(6), 948–949. https://doi.org/10.1016/j.jsxm.2019.03.407 Aitken, M., Steensma, T. D., Blanchard, R., VanderLaan, D. P., Wood, H., Fuentes, A., Spegg, C., Wasserman, L., Ames, M., Fitzsimmons, C. L., Leef, J. H., Lishak, V., Reim, E., Takagi, A., Vinik, J., Wreford, J., Cohen-Kettenis, P. T., de Vries, A. L., Kreukels, B. P., & Zucker, K. J. (2015). Evidence for an altered sex ratio in

clinic-referred adolescents with gender dysphoria. The journal of sexual medicine, 12(3), 756–763. Baldassarre, M., Giannone, F. A., Foschini, M. P., Battaglia, C., Busacchi, P., Venturoli, S., & Meriggiola, M. C. (2013). Effects of long-term high dose testosterone administration on vaginal epithelium structure and estrogen receptor-α and -β expression of young women. International Journal of Impotence Research, 25(5), 172–177. https://doi.org/10.1038/ijir.2013.9 Barrett, J. (2015). Written evidence submitted by British Association of Gender Identity Specialists to the Transgender Equality Inquiry. Data.parliament.uk Bartlett, N. H., & Vasey, P. L. (2006). A retrospective study of childhood gender-atypical behavior in Samoan fa'afafine. Archives of sexual behavior, 35(6), 659–666. Bettocchi, C., Ralph, D. J., & Pryor, J. P. (2005). Pedicled pubic phalloplasty in females with gender dysphoria. BJU international, 95(1), 120–124. Bhargava, A., Arnold, A. P., Bangasser, D. A., Denton, K. M., Gupta, A., Hilliard Krause, L. M., Mayer, E. A., McCarthy, M., Miller, W. L., Raznahan, A., & Verma, R. (2021). Considering Sex as a Biological Variable in Basic and Clinical Studies: An Endocrine Society Scientific Statement. Endocrine Reviews. https://doi.org/10.1210/endrev/bnaa034 Biggs, M. (2021). Revisiting the effect of GnRH analogue treatment on bone mineral density in young adolescents with gender dysphoria. Journal of Pediatric Endocrinology and Metabolism, 0(0). https://doi.org/10.1515/jpem-2021-0180

Brass, M., & Heyes, C. (2005). Imitation: is cognitive neuroscience solving the correspondence problem? Trends in Cognitive Sciences, 9(10), 489–495. https://doi.org/10.1016/j.tics.2005.08.007 Burgess, L. G., Riddell, P. M., Fancourt, A., & Murayama, K. (2018). The Influence of Social Contagion Within Education: A Motivational Perspective. Mind, Brain, and Education, 12(4), 164–174. https://doi.org/10.1111/mbe.12178 Cacioppo, J. T., Fowler, J. H., & Christakis, N. A. (2008). Alone in the Crowd: The Structure and Spread of Loneliness in a Large Social Network. SSRN Electronic Journal. https://doi.org/10.2139/ssrn.1319108 Carmichael, P., Butler, G., Masic, U., Cole, T. J., De Stavola, B. L., Davidson, S., Skageberg, E. M., Khadr, S., & Viner, R. M. (2021). Short-term outcomes of pubertal suppression in a selected cohort of 12 to 15 year old young people with persistent gender dysphoria in the UK. PLOS ONE, 16(2), e0243894. https://doi.org/10.1371/journal.pone.0243894 Carr, C. L. (2005). Tomboyism or Lesbianism? Beyond Sex/Gender/Sexual Conflation. Sex Roles, 53(1-2), 119–131. https://doi.org/10.1007/s11199-005-4286-5 Caspers, S., Zilles, K., Laird, A. R., & Eickhoff, S. B. (2010). ALE meta-analysis of action observation and imitation in the human brain. NeuroImage, 50(3), 1148–1167. https://doi.org/10.1016/j.neuroimage.2009.12.112 Cattaneo, L., & Rizzolatti, G. (2009). The Mirror Neuron System. Archives of Neurology, 66(5). https://doi.org/10.1001/archneurol.2009.41 Chartrand, T. L., & Bargh, J. A. (1999). The chameleon effect: The perception–behavior link and social interaction. Journal of Personality and Social Psychology, 76(6),

893–910. https://doi.org/10.1037/0022-3514.76.6.893 Chartrand, T. L., & Lakin, J. L. (2013). The Antecedents and Consequences of Human Behavioral Mimicry. Annual Review of Psychology, 64(1), 285–308. https://doi.org/10.1146/annurev-psych-113011-143754 Cheng, P. J., Pastuszak, A. W., Myers, J. B., Goodwin, I. A., & Hotaling, J. M. (2019). Fertility concerns of the transgender patient. Translational Andrology and Urology, 8(3), 209–218. https://doi.org/10.21037/tau.2019.05.09

CM, W., NM, N., CJM, de B., M, K., ALC, de V., SA, W.-K., RT, de J., MB, B., TD, S., P, C.-K., LJG, G., BPC, K., & M, den H. (2018). The Amsterdam Cohort of Gender Dysphoria Study (1972-2015): Trends in Prevalence, Treatment, and Regrets. Yearbook of Paediatric Endocrinology. https://doi.org/10.1530/ey.15.6.4 Cohen-Bendahan, C. C. C., van de Beek, C., & Berenbaum, S. A. (2005). Prenatal sex hormone effects on child and adult sex-typed behavior: methods and findings. Neuroscience & Biobehavioral Reviews, 29(2), 353–384. Coleman, E., Bockting, W., Botzer, M., Cohen-Kettenis, P., DeCuypere, G., Feldman, J., ... & Zucker, K. (2012). Standards of care for the health of transsexual, transgender, and gender-nonconforming people, version 7. International journal of transgenderism, 13(4), 165-232. Cumming, R. J. M., Sylvester, K., & Fuld, J. (2016). P257 Understanding the effects on lung function of chest binder use in the transgender population. de Vries, A. L. C., & Cohen-Kettenis, P. T. (2012). Clinical Management of Gender Dysphoria in Children and Adolescents: The Dutch Approach. Journal of Homosexuality, 59(3), 301–320. https://doi.org/10.1080/00918369.2012.653300

de Vries, A. L. C., McGuire, J. K., Steensma, T. D., Wagenaar, E. C. F., Doreleijers, T. A. H., & Cohen-Kettenis, P. T. (2014). Young Adult Psychological Outcome After Puberty Suppression and Gender Reassignment. PEDIATRICS, 134(4), 696–704. https://doi.org/10.1542/peds.2013-2958 de Vries, A. L. C., Steensma, T. D., Doreleijers, T. A. H., & Cohen‐Kettenis, P. T. (2011). Puberty Suppression in Adolescents With Gender Identity Disorder: A Prospective Follow‐Up Study. The Journal of Sexual Medicine, 8(8), 2276–2283. https://doi.org/10.1111/j.1743-6109.2010.01943. Delahunt, J. W., Denison, H. J., Sim, D. A., Bullock, J. J., & Krebs, J. D. (2018). Increasing rates of people identifying as transgender presenting to Endocrine Services in the Wellington region. The New Zealand medical journal, 131(1468), 33–42. Delgado-Ruiz, R., Swanson, P., & Romanos, G. (2019). Systematic Review of the Long-Term Effects of Transgender Hormone Therapy on Bone Markers and Bone Mineral Density and Their Potential Effects in Implant Therapy. Journal of Clinical Medicine, 8(6), E784. https://doi.org/10.3390/jcm8060784 Elhakeem, A., Frysz, M., Tilling, K., Tobias, J. H., & Lawlor, D. A. (2019). Association between age at puberty and bone accrual up to 25 years-old. Bone Abstracts. https://doi.org/10.1530/boneabs.7.oc1 Frenzel, A. C., Goetz, T., Lüdtke, O., Pekrun, R., & Sutton, R. E. (2009). Emotional transmission in the classroom: Exploring the relationship between teacher and student enjoyment. Journal of Educational Psychology, 101(3), 705–716. https://doi.org/10.1037/a0014695

Frenzel, A. C., Pekrun, R., & Goetz, T. (2007). Perceived learning environment and students’ emotional experiences: A multilevel analysis of mathematics classrooms. Learning and Instruction, 17(5), 478–493. https://doi.org/10.1016/j.learninstruc.2007.09.001 Gallese, V. (2009). Mirror Neurons, Embodied Simulation, and the Neural Basis of Social Identification. Psychoanalytic Dialogues, 19(5), 519–536. https://doi.org/10.1080/10481880903231910 Gender Identity Development Service (2021). Referrals to GIDS, financial years 2010-11 to 2020-21 Hatfield, E., Bensman, L., Thornton, P. D., & Rapson, R. L. (2014). New Perspectives on Emotional Contagion: A Review of Classic and Recent Research on Facial Mimicry and Contagion. Interpersona: An International Journal on Personal Relationships, 8(2), 159–179. https://doi.org/10.5964/ijpr.v8i2.162 Hess, U., & Fischer, A. (2014). Emotional Mimicry: Why and When We Mimic Emotions. Social and Personality Psychology Compass, 8(2), 45–57. https://doi.org/10.1111/spc3.12083 Houser, M. L., & Waldbuesser, C. (2016). Emotional Contagion in the Classroom: The Impact of Teacher Satisfaction and Confirmation on Perceptions of Student Nonverbal Classroom Behavior. College Teaching, 65(1), 1–8. Kaltiala-Heino, R., Sumia, M., Työläjärvi, M., & Lindberg, N. (2015). Two years of gender identity service for minors: overrepresentation of natal girls with severe problems in adolescent development. Child and Adolescent Psychiatry and Mental Health, 9(1). https://doi.org/10.1186/s13034-015-0042-y King, R. B., & Mendoza, N. B. (2021). The social contagion of students’ social goals and its influence on engagement in school. Learning and Individual Differences, 88, 102004. https://doi.org/10.1016/j.lindif.2021.102004 Kuyper, L., & Wijsen, C. (2014). Gender identities and gender dysphoria in the Netherlands. Archives of sexual behavior, 43(2), 377-385. Littman, L. (2019). Parent reports of adolescents and young adults perceived to show signs of a rapid onset of gender dysphoria. Yearbook of Paediatric Endocrinology. https://doi.org/10.1530/ey.16.6.13 Lee, J. Y., Finlayson, C., Olson-Kennedy, J., Garofalo, R., Chan, Y.-M., Glidden, D. V., & Rosenthal, S. M. (2020). Low Bone Mineral Density in Early Pubertal Transgender/Gender Diverse Youth: Findings From the Trans Youth Care Study. Journal of the Endocrine Society, 4(9). https://doi.org/10.1210/jendso/bvaa065 Lehne, G. K. (1998). Gender Identity Disorder and Psychosexual Problems in Children and Adolescents. The Journal of Nervous & Mental Disease, 186(2), 129. https://doi.org/10.1097/00005053-199802000-00014 Leung, A. K. ., Qiu, L., Ong, L., & Tam, K.-P. (2011). Embodied Cultural Cognition: Situating the Study of Embodied Cognition in Socio-Cultural Contexts. Social and Personality Psychology Compass, 5(9), 591–608. Lippa, R.A. The Relation Between Childhood Gender Nonconformity and Adult Masculinity–Femininity and Anxiety in Heterosexual and Homosexual Men and Women. Sex Roles 59, 684 (2008). Littman, L. (2021). Individuals Treated for Gender Dysphoria with Medical and/or Surgical Transition Who Subsequently Detransitioned: A Survey of 100 Detransitioners. Archives of Sexual Behavior, 50(8), 3353–3369. https://doi.org/10.1007/s10508-021-02163-w Madsen, M. C., van Dijk, D., Wiepjes, C., Conemans, E., Thijs, A., & Den Heijer, M. (2021). Erythrocytosis in a Large Cohort of Trans Men Using Testosterone: A Long Term Follow up Study on Prevalence, Determinants, and the Effect of Years of Exposure. Journal of the Endocrine Society, 5(Supplement_1), A726–A726. https://doi.org/10.1210/jendso/bvab048.1477 Marchiano, L. (2017). Outbreak: On Transgender Teens and Psychic Epidemics. Psychological Perspectives, 60(3), 345–366. Mottet, T. P., & Beebe, S. A. (2000). Emotional Contagion in the Classroom: An Examination of How Teacher and Student Emotions Are Related. Neave, N., Menaged, M., & Weightman, D. R. (1999). Sex differences in cognition: the role of testosterone and sexual orientation. Brain and cognition, 41(3), 245–262. Nordentoft, M., Madsen, T., & Fedyszyn, I. (2015). Suicidal Behavior and Mortality in First-Episode Psychosis. The Journal of Nervous and Mental Disease, 203(5), 387–392. https://doi.org/10.1097/nmd.0000000000000296 Nota, N. M., Wiepjes, C. M., de Blok, C. J. M., Gooren, L. J. G., Kreukels, B. P. C., & den Heijer, M. (2019). Occurrence of Acute Cardiovascular Events in Transgender Individuals Receiving Hormone Therapy. Circulation, 139(11), 1461–1462. https://doi.org/10.1161/circulationaha.118.038584

Pang, K. C., Notini, L., McDougall, R., Gillam, L., Savulescu, J., Wilkinson, D., Clark, B. A., Olson-Kennedy, J., Telfer, M. M., & Lantos, J. D. (2020). Long-term Puberty Suppression for a Nonbinary Teenager. Pediatrics, 145(2). https://doi.org/10.1542/peds.2019-1606 Parr, J. M., & Townsend, M. A. R. (2002). Environments, processes, and mechanisms in peer learning. International Journal of Educational Research, 37(5), 403–423. https://doi.org/10.1016/s0883-0355(03)00013-2 Peitzmeier, S. M., Silberholz, J., Gardner, I. H., Weinand, J., & Acevedo, K. (2021). Time to First Onset of Chest Binding–Related Symptoms in Transgender Youth. Pediatrics, 147(3). https://doi.org/10.1542/peds.2020-0728 Peitzmeier, S., Gardner, I., Weinand, J., Corbet, A., & Acevedo, K. (2016). Health impact of chest binding among transgender adults: a community-engaged, cross-sectional study. Culture, Health & Sexuality, 19(1), 64–75. https://doi.org/10.1080/13691058.2016.1191675 Poteat, T., Malik, M., & Cooney, E. (2018). 2148 Understanding the health effects of binding and tucking for gender affirmation. Journal of Clinical and Translational Science, 2(S1), 76–76. https://doi.org/10.1017/cts.2018.268 Shah, K. McCormack, C. & Bradbury, N. (2014). Do you know the sex of your cells?’ American Journal of Physiology – Cell Physiology Sax, L. (2002). How common is lntersex? A response to Anne Fausto‐Sterling. Journal of Sex Research, 39(3), 174–178. https://doi.org/10.1080/00224490209552139 Shansky, R. M., & Murphy, A. Z. (2021). Considering sex as a biological variable will require a global shift in science culture. Nature Neuroscience, 24(4), 457–464.

Singh D, Bradley SJ, Zucker KJ. A Follow-Up Study of Boys With Gender Identity Disorder. Front Psychiatry. 2021 Mar 29;12:632784 Skidmore, W.C., Linsenmeier, J.A.W. & Bailey, J.M. Gender Nonconformity and Psychological Distress in Lesbians and Gay Men. Arch Sex Behav 35, 685–697 (2006). Spack, N. P., Edwards-Leeper, L., Feldman, H. A., Leibowitz, S., Mandel, F., Diamond, D. A., & Vance, S. R. (2012). Children and adolescents with gender identity disorder referred to a pediatric medical center. Pediatrics, 129(3), 418-425. Stallen, M., & Sanfey, A. G. (2015). The neuroscience of social conformity: implications for fundamental and applied research. Frontiers in Neuroscience, 9(1). https://doi.org/10.3389/fnins.2015.00337 Steensma, T. D., & Cohen-Kettenis, P. T. (2011). Gender Transitioning before Puberty? Archives of Sexual Behavior, 40(4), 649–650. https://doi.org/10.1007/s10508-011-9752-2 Steensma, T. D., McGuire, J. K., Kreukels, B. P. C., Beekman, A. J., & Cohen-Kettenis, P. T. (2013). Factors Associated With Desistence and Persistence of Childhood Gender Dysphoria: A Quantitative Follow-Up Study. Journal of the American Academy of Child & Adolescent Psychiatry, 52(6), 582–590. https://doi.org/10.1016/j.jaac.2013.03.016 Steensma, T. D., van der Ende, J., Verhulst, F. C., & Cohen‐Kettenis, P. T. (2013). Gender Variance in Childhood and Sexual Orientation in Adulthood: A Prospective Study. The Journal of Sexual Medicine, 10(11), 2723–2733. https://doi.org/10.1111/j.1743-6109.2012.02701.x

Suzuki, S., Jensen, E. L. S., Bossaerts, P., & O’Doherty, J. P. (2016). Behavioral contagion during learning about another agent’s risk-preferences acts on the neural representation of decision-risk. Proceedings of the National Academy of Sciences, 113(14), 3755–3760. https://doi.org/10.1073/pnas.1600092113 Swedish National Board of Health and Welfare (2020). Utvecklingen av diagnosen könsdysfori: Förekomst, samtidiga psykiatriska diagnoser och dödlighet i suicid. Socialstyrelsen Swift-Gallant, A., Shirazi, T., Puts, D. A., & Breedlove, S. M. (2022). Evidence for Perinatal Steroid Influence on Human Sexual Orientation and Gendered Behavior. Cold Spring Harbor perspectives in biology, 14(8), a039123. Tamura, A., Ishii, R., Yagi, A., Fukuzumi, N., Hatano, A., Sakaki, M., Tanaka, A., & Murayama, K. (2022). Exploring the within-person contemporaneous network of motivational engagement. Learning and Instruction. Tanis, J. (2016). The power of 41%: A glimpse into the life of a statistic. Am J Orthopsychiatry. Tiedemann, B. L. (2022). School-Based Mental Health Programs for Preadolescent Girls: Mitigating Social Contagion of Non-Suicidal Self-Injury. Canadian Journal of Counselling and Psychotherapy, 56(1), 24–46. https://doi.org/10.47634/cjcp.v56i1.71662 Tredinnick, J. (2015). A student-centred approach to support, reward and recognition of student peer’learnership’. In Proceedings of the 2015 Students Transitions Achievement Retention and Success (STARS) Conference (pp. 1-10).

Van Volkom, M. (2003). The Relationships Between Childhood Tomboyism, Siblings’ Activities, and Adult Gender Roles. Sex Roles, 49(11/12), 609–618. https://doi.org/10.1023/b:sers.0000003131.98867.a1 Vandenbussche, E. (2021). Detransition-Related Needs and Support: A Cross-Sectional Online Survey. Journal of Homosexuality, 1–19. https://doi.org/10.1080/00918369.2021.1919479 Vasey, P. L., & Bartlett, N. H. (2007). What can the Samoan "Fa'afafine" teach us about the Western concept of gender identity disorder in childhood?. Perspectives in biology and medicine, 50(4), 481–490 Vlot, M. C., Wiepjes, C. M., Jongh, R. T., T’Sjoen, G., Heijboer, A. C., & den Heijer, M. (2019). Gender‐Affirming Hormone Treatment Decreases Bone Turnover in Transwomen and Older Transmen. Journal of Bone and Mineral Research, 34(10), 1862–1872. https://doi.org/10.1002/jbmr.3762 Wallien, M. S. C., & Cohen-Kettenis, P. T. (2008a). Psychosexual Outcome of Gender-Dysphoric Children. Journal of the American Academy of Child & Adolescent Psychiatry, 47(12), 1413–1423. https://doi.org/10.1097/chi.0b013e31818956b9 Wallien, M. S. C., & Cohen-Kettenis, P. T. (2008b). Psychosexual Outcome of Gender-Dysphoric Children. Journal of the American Academy of Child & Adolescent Psychiatry, 47(12), 1413–1423. https://doi.org/10.1097/chi.0b013e31818956b9 Wiepjes, C. M., Nota, N. M., de Blok, C. J. M., Klaver, M., de Vries, A. L. C., Wensing-Kruger, S. A., de Jongh, R. T., Bouman, M.-B., Steensma, T. D.,

Cohen-Kettenis, P., Gooren, L. J. G., Kreukels, B. P. C., & den Heijer, M. (2018). The Amsterdam Cohort of Gender Dysphoria Study (1972–2015): Trends in Prevalence, Treatment, and Regrets. The Journal of Sexual Medicine, 15(4), 582–590. https://doi.org/10.1016/j.jsxm.2018.01.016 Wierckx, K., Mueller, S., Weyers, S., Van Caenegem, E., Roef, G., Heylens, G., & T’Sjoen, G. (2012). Long-term evaluation of cross-sex hormone treatment in transsexual persons. The Journal of Sexual Medicine, 9(10), 2641–2651. https://doi.org/10.1111/j.1743-6109.2012.02876.x Wu, H., Luo, Y., & Feng, C. (2016). Neural signatures of social conformity: A coordinate-based activation likelihood estimation meta-analysis of functional brain imaging studies. Neuroscience & Biobehavioral Reviews, 71, 101–111. https://doi.org/10.1016/j.neubiorev.2016.08.038 Xu, Y., Norton, S., & Rahman, Q. (2017). Sexual orientation and neurocognitive ability: A meta-analysis in men and women. Neuroscience and biobehavioral reviews, 83, 691–696 Zucker, K. J. (2017). Epidemiology of gender dysphoria and transgender identity. Sexual Health, 14(5), 404. https://doi.org/10.1071/sh17067 Zucker, K. J. (2019a). Debate: Different strokes for different folks. Child and Adolescent Mental Health. https://doi.org/10.1111/camh.12330 Zucker, K. J. (2019b). Adolescents with Gender Dysphoria: Reflections on Some Contemporary Clinical and Research Issues. Archives of Sexual Behavior, 48(7), 1983–1992. https://doi.org/10.1007/s10508-019-01518-8 Zucker, K. J., Bradley, S. J., Owen-Anderson, A., Kibblewhite, S. J., Wood, H., Singh,

D., & Choi, K. (2012). Demographics, Behavior Problems, and Psychosexual Characteristics of Adolescents with Gender Identity Disorder or Transvestic Fetishism. Journal of Sex & Marital Therapy, 38(2), 151–189. https://doi.org/10.1080/0092623x.2011.611219