Representatives of some pediatric gender clinics have reported an increase in transgender and gender diverse (TGD) adolescents presenting for care who were assigned female sex at birth (AFAB) relative to those assigned male sex at birth (AMAB). These data have been used to suggest that youth come to identify as TGD because of “social contagion,” with the underlying assumption that AFAB youth are uniquely vulnerable to this hypothesized phenomenon. Reported changes in the AMAB:AFAB ratio have been cited in recent legislative debates regarding the criminalization of gender-affirming medical care. Our objective was to examine the AMAB:AFAB ratio among United States TGD adolescents in a larger and more representative sample than past clinic-recruited samples.
Using the 2017 and 2019 Youth Risk Behavior Survey across 16 states that collected gender identity data, we calculated the AMAB:AFAB ratio for each year. We also examined the rates of bullying victimization and suicidality among TGD youth compared with their cisgender peers.
The analysis included 91 937 adolescents in 2017 and 105 437 adolescents in 2019. In 2017, 2161 (2.4%) participants identified as TGD, with an AMAB:AFAB ratio of 1.5:1. In 2019, 1640 (1.6%) participants identified as TGD, with an AMAB:AFAB ratio of 1.2:1. Rates of bullying victimization and suicidality were higher among TGD youth when compared with their cisgender peers.
The sex assigned at birth ratio of TGD adolescents in the United States does not appear to favor AFAB adolescents and should not be used to argue against the provision of gender-affirming medical care for TGD adolescents.
Representatives of some pediatric gender clinics have reported an increase in transgender youth assigned female sex at birth relative to those assigned male sex at birth. Such data have been used to suggest a theory of social contagion leading to transgender identity.
Our findings from a national sample of adolescents across 16 states reveal that the sex assigned at birth ratio of transgender adolescents does not favor transgender adolescents assigned female sex at birth.
Transgender and gender diverse (TGD) youth are those whose gender identity does not strictly align with societal expectations based on their sex assigned at birth.1 Some TGD youth experience gender dysphoria, which, as currently described in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision refers to the distress that arises secondary to one’s gender identity being incongruent with societal expectations based on one’s sex assigned at birth.2
A recent descriptive article hypothesized the existence of a new subtype of gender dysphoria, putatively termed “rapid-onset gender dysphoria” (ROGD).3 The ROGD hypothesis asserts that young people begin to identify as TGD for the first time as adolescents rather than as prepubertal children and that this identification and subsequent gender dysphoria are the result of social contagion. This hypothesis further asserts that youth assigned female sex at birth (AFAB) are more susceptible to social contagion than those assigned male sex at birth (AMAB),3 with a resultant expectation of increasing overrepresentation of TGD AFAB youth relative to TGD AMAB youth.
Of note, this hypothesis was formed solely through the analysis of online parental survey data. As a subsequently issued correction to the article outlined, “ROGD is not a formal mental health diagnosis at this time. This report did not collect data from the adolescents and young adults or clinicians and therefore does not validate the phenomenon.”4
Despite this parent-centered study prompting substantial social5 and methodological6 critique in tandem with calls for more robust research studies with samples of TGD adolescents,7 the notion of ROGD has been used in recent legislative debates to argue for and subsequently enact policies that prohibit gender-affirming medical care for TGD adolescents.8 Notably, all relevant major medical organizations, including the American Academy of Pediatrics, oppose such legislative efforts.8
One element of the ROGD hypothesis has been understudied, namely, the sex assigned at birth ratio of TGD adolescents (ie, the number of TGD AFAB adolescents relative to the number of TGD AMAB adolescents). Although representatives of some pediatric gender clinics have reported an increase in TGD AFAB patients relative to TGD AMAB patients,9,10 there is a dearth of studies that explore this ratio in larger, national samples of adolescents. Using data from the 2017 and 2019 iterations of the Youth Risk Behavior Survey (YRBS) across 16 US states, we explored this component of the ROGD hypothesis and examined the AMAB:AFAB ratio among United States TGD adolescents in a larger and more representative sample than past clinic-recruited samples. Moreover, to test the assertion that youth identify as TGD because of social desirability, we also examined rates of bullying among those who identified as TGD and those who did not. We further compared rates of bullying victimization among TGD youth with rates among cisgender sexual minority youth because some have asserted that TGD youth identify as TGD because of their underlying sexual orientation and presumption that TGD identities are less stigmatized than sexual minority cisgender identities.11
Methods
Data Source and Study Population
Data for this study come from the 2017 and 2019 iterations of the YRBS, which is a biennial survey of high school students in the United States conducted by the Centers for Disease Control and Prevention, with the objective of assessing risk behaviors among United States adolescents. The complete YRBS methodology (ie, sampling methodology, data collection processes, response rates) has previously been described.12 Sixteen states that administered the YRBS in 2017 and 2019 collected gender identity data. Because data were publicly available, this study was exempt from institutional review board review.
Gender Identity
Participants were asked, “Some people describe themselves as transgender when their sex at birth does not match the way they think or feel about their gender. Are you transgender?” Response options were “Yes, I am transgender,” “No, I am not transgender,” “I am not sure if I am transgender,” and “I do not know what this question is asking.” Youth who chose “I am not sure if I am transgender” and “I do not know what this question is asking” were excluded from analyses.
Sex Assigned at Birth
Youth reported their sex assigned at birth by answering: “What is your sex?” Response options were female or male. Although this question does not refer to sex assigned at birth specifically, several studies have found that TGD youth are likely to understand “sex” to be sex assigned at birth rather than gender identity, due to the foundational salience of these characteristics to their identities.13,14,15 For this reason, we conceptualize responses to this question as referring to sex assigned at birth. Survey questions used to ascertain gender identity and sex assigned at birth are displayed in Supplemental Table 5.
Demographic, Bullying, and Mental Health Variables
Demographic variables including age, grade, race/ethnicity, and sexual orientation were collected. Because proponents of ROGD have argued that youth are increasingly identifying as TGD because of social desirability,11 variables related to school bullying and electronic bullying were also included in the study analyses, to examine the veracity of these assertions. Moreover, because bullying is a predictor of negative mental health outcomes,1 we also included history of suicide attempts as a variable in the analyses.
Statistical Analyses
Percentages were calculated to determine the proportion of TGD adolescents overall as well as by sex assigned at birth. AMAB:AFAB ratios were calculated to compare the number of AFAB and AMAB participants who identified as TGD. Variables related to demographics, bullying, and suicidality were compared between TGD and cisgender youth by using χ2 tests.
Results
The analyses included 91 937 adolescents in 2017 and 105 437 adolescents in 2019. The percentages of excluded youth who indicated “I am not sure if I am transgender” or “I do not know what this question is asking” were 4.0% (n = 3785) and 3.2% (n = 3505) in 2017 and 2019, respectively. TGD and cisgender youth demonstrated significant differences across all demographic variables, bullying victimization, and suicidality (Table 1). TGD youth were more likely to be victims of school bullying and electronic bullying when compared with their cisgender peers, and they were also more likely to endorse a history of suicide attempts.
YRBS Year . | 2017a . | . | 2019b . | . | ||
---|---|---|---|---|---|---|
. | Cisgender, n = 89 776 . | Transgender, n = 2161 . | P . | Cisgender, n = 103 797 . | Transgender, n = 1640 . | P . |
Sex assigned at birth, n (%) | <.001 | .001 | ||||
Female, AFAB | 45 928 (51.2) | 876 (40.5) | 53 179 (51.2) | 774 (47.2) | ||
Male, AMAB | 43 848 (48.8) | 1285 (59.5) | 50 618 (48.8) | 866 (52.8) | ||
Age, y | <.001 | <.001 | ||||
≤12 | 235 (0.3) | 142 (6.6) | 208 (0.2) | 110 (6.7) | ||
13 | 209 (0.2) | 19 (0.9) | 443 (0.4) | 37 (2.3) | ||
14 | 14 326 (16.0) | 310 (14.4) | 17 933 (17.3) | 227 (13.9) | ||
15 | 23 947 (26.7) | 504 (23.4) | 28 377 (27.4) | 351 (21.5) | ||
16 | 24 005 (26.8) | 504 (23.4) | 26 648 (25.7) | 361 (22.1) | ||
17 | 20 250 (22.6) | 464 (21.5) | 22 287 (21.5) | 358 (21.9) | ||
≥18 | 6726 (7.5) | 201 (9.3) | 7804 (7.5) | 192 (11.7) | ||
Grade, n (%) | .009 | .001 | ||||
9th | 24 706 (27.7) | 557 (27.2) | 29 648 (28.8) | 403 (25.7) | ||
10th | 23 760 (26.7) | 529 (25.8) | 27 840 (27.0) | 407 (25.9) | ||
11th | 23 033 (25.8) | 496 (24.2) | 25 216 (24.5) | 392 (25.0) | ||
12th | 17 609 (19.8) | 465 (22.7) | 20 361 (19.8) | 368 (23.4) | ||
Race/ethnicity, n (%) | <.001 | <.001 | ||||
American Indian/Alaska Native | 1110 (1.3) | 34 (1.7) | 1022 (1.0) | 27 (1.7) | ||
Asian | 5097 (5.8) | 94 (4.6) | 6123 (6.0) | 81 (5.2) | ||
Black or African American | 11 641 (13.3) | 430 (21.2) | 14 259 (14.0) | 140 (9.0) | ||
Hispanic/Latino | 9415 (10.7) | 396 (19.5) | 16 500 (16.2) | 408 (26.4) | ||
Native Hawaiian/Other Pacific Islander | 1783 (2.0) | 78 (3.8) | 2131 (2.1) | 52 (3.4) | ||
White | 52 859 (60.3) | 860 (42.3) | 55 261 (54.4) | 734 (47.4) | ||
Multiracial | 5767 (6.6) | 140 (6.9) | 6301 (6.2) | 105 (6.8) | ||
Sexual orientation, n (%) | <.001 | <.001 | ||||
Heterosexual | 77 451 (87.1) | 761 (37.5) | 88 172 (85.6) | 403 (25.3) | ||
Gay or lesbian | 1932 (2.2) | 465 (22.96) | 2236 (2.2) | 442 (27.7) | ||
Bisexual | 6462 (7.3) | 545 (26.8) | 8546 (8.3) | 530 (33.2) | ||
Not sure | 3117 (3.5) | 261 (12.8) | 4012 (3.9) | 220 (13.8) | ||
Bullied at school,cn (%) | 13 052 (14.5) | 675 (31.2) | <.001 | 15 494 (14.9) | 567 (34.6) | <.001 |
Electronically bullied,dn (%) | 13 291 (14.8) | 628 (29.1) | <.001 | 15 089 (14.5) | 573 (34.9) | <.001 |
Attempted suicide,en (%) | <.001 | <.001 | ||||
0 times | 41 015 (94.0) | 428 (67.0) | 56 131 (92.7) | 617 (69.2) | ||
1 time | 1577 (3.6) | 75 (11.7) | 2649 (4.4) | 111 (12.5) | ||
2 or 3 times | 708 (1.6) | 62 (9.7) | 1221 (2.0) | 79 (8.9) | ||
4 or 5 times | 138 (0.3) | 13 (2.0) | 241 (0.4) | 23 (2.6) | ||
6 or more times | 175 (0.4) | 61 (9.5) | 277 (0.5) | 61 (6.8) |
YRBS Year . | 2017a . | . | 2019b . | . | ||
---|---|---|---|---|---|---|
. | Cisgender, n = 89 776 . | Transgender, n = 2161 . | P . | Cisgender, n = 103 797 . | Transgender, n = 1640 . | P . |
Sex assigned at birth, n (%) | <.001 | .001 | ||||
Female, AFAB | 45 928 (51.2) | 876 (40.5) | 53 179 (51.2) | 774 (47.2) | ||
Male, AMAB | 43 848 (48.8) | 1285 (59.5) | 50 618 (48.8) | 866 (52.8) | ||
Age, y | <.001 | <.001 | ||||
≤12 | 235 (0.3) | 142 (6.6) | 208 (0.2) | 110 (6.7) | ||
13 | 209 (0.2) | 19 (0.9) | 443 (0.4) | 37 (2.3) | ||
14 | 14 326 (16.0) | 310 (14.4) | 17 933 (17.3) | 227 (13.9) | ||
15 | 23 947 (26.7) | 504 (23.4) | 28 377 (27.4) | 351 (21.5) | ||
16 | 24 005 (26.8) | 504 (23.4) | 26 648 (25.7) | 361 (22.1) | ||
17 | 20 250 (22.6) | 464 (21.5) | 22 287 (21.5) | 358 (21.9) | ||
≥18 | 6726 (7.5) | 201 (9.3) | 7804 (7.5) | 192 (11.7) | ||
Grade, n (%) | .009 | .001 | ||||
9th | 24 706 (27.7) | 557 (27.2) | 29 648 (28.8) | 403 (25.7) | ||
10th | 23 760 (26.7) | 529 (25.8) | 27 840 (27.0) | 407 (25.9) | ||
11th | 23 033 (25.8) | 496 (24.2) | 25 216 (24.5) | 392 (25.0) | ||
12th | 17 609 (19.8) | 465 (22.7) | 20 361 (19.8) | 368 (23.4) | ||
Race/ethnicity, n (%) | <.001 | <.001 | ||||
American Indian/Alaska Native | 1110 (1.3) | 34 (1.7) | 1022 (1.0) | 27 (1.7) | ||
Asian | 5097 (5.8) | 94 (4.6) | 6123 (6.0) | 81 (5.2) | ||
Black or African American | 11 641 (13.3) | 430 (21.2) | 14 259 (14.0) | 140 (9.0) | ||
Hispanic/Latino | 9415 (10.7) | 396 (19.5) | 16 500 (16.2) | 408 (26.4) | ||
Native Hawaiian/Other Pacific Islander | 1783 (2.0) | 78 (3.8) | 2131 (2.1) | 52 (3.4) | ||
White | 52 859 (60.3) | 860 (42.3) | 55 261 (54.4) | 734 (47.4) | ||
Multiracial | 5767 (6.6) | 140 (6.9) | 6301 (6.2) | 105 (6.8) | ||
Sexual orientation, n (%) | <.001 | <.001 | ||||
Heterosexual | 77 451 (87.1) | 761 (37.5) | 88 172 (85.6) | 403 (25.3) | ||
Gay or lesbian | 1932 (2.2) | 465 (22.96) | 2236 (2.2) | 442 (27.7) | ||
Bisexual | 6462 (7.3) | 545 (26.8) | 8546 (8.3) | 530 (33.2) | ||
Not sure | 3117 (3.5) | 261 (12.8) | 4012 (3.9) | 220 (13.8) | ||
Bullied at school,cn (%) | 13 052 (14.5) | 675 (31.2) | <.001 | 15 494 (14.9) | 567 (34.6) | <.001 |
Electronically bullied,dn (%) | 13 291 (14.8) | 628 (29.1) | <.001 | 15 089 (14.5) | 573 (34.9) | <.001 |
Attempted suicide,en (%) | <.001 | <.001 | ||||
0 times | 41 015 (94.0) | 428 (67.0) | 56 131 (92.7) | 617 (69.2) | ||
1 time | 1577 (3.6) | 75 (11.7) | 2649 (4.4) | 111 (12.5) | ||
2 or 3 times | 708 (1.6) | 62 (9.7) | 1221 (2.0) | 79 (8.9) | ||
4 or 5 times | 138 (0.3) | 13 (2.0) | 241 (0.4) | 23 (2.6) | ||
6 or more times | 175 (0.4) | 61 (9.5) | 277 (0.5) | 61 (6.8) |
Note: All variables have <3% missing data except for attempted suicide (52% and 42% missing in 2017 and 2019, respectively).
2017 YRBS data come from the following states: Colorado, Delaware, Hawaii, Maine, Maryland, Massachusetts, Michigan, Rhode Island, Vermont, Virginia, and Wisconsin.
2019 YRBS data come from the following states: Colorado, Florida, Hawaii, Maine, Maryland, Massachusetts, Michigan, Nevada, New Jersey, New York, Pennsylvania, Rhode Island, Vermont, Virginia, and Wisconsin.
Bullied on school property in the past 12 mo, “During the past 12 months, have you ever been bullied on school property” (response options “Yes” or “No).
Bullied through texting, Instagram, Facebook, or other social media in the past 12 mo, “During the past 12 months, have you ever been electronically bullied? (Count being bullied through texting, Instagram, Facebook, or other social media” (response options “Yes” or “No”).
Number of suicide attempts in the past 12 mo, “During the past 12 months, how many times did you actually attempt suicide?” (response options those listed in table).
Table 2 highlights the numbers and percentages of TGD adolescents by year and sex assigned at birth. In 2017, 2161 (2.4%) of participants identified as TGD, with an AMAB:AFAB ratio of 1.5:1. In 2019, 1640 (1.6% of) participants identified as TGD, with an AMAB:AFAB ratio of 1.2:1.
YRBS Year . | 2017 . | 2019 . |
---|---|---|
All adolescents, n (%) | ||
Transgender | 2161 (2.4) | 1640 (1.6) |
Cisgender | 89 776 (97.6) | 103 797 (98.4) |
AMAB adolescents, n (%) | ||
Transgender | 1285 (2.8) | 866 (1.7) |
Cisgender | 43 848 (97.2) | 50 618 (98.3) |
AFAB adolescents, n (%) | ||
Transgender | 876 (1.9) | 774 (1.4) |
Cisgender | 45 928 (98.1) | 53 179 (98.6) |
Sex assigned at birth ratio, transgender AMAB:transgender AFAB | 1.5:1 | 1.2:1 |
YRBS Year . | 2017 . | 2019 . |
---|---|---|
All adolescents, n (%) | ||
Transgender | 2161 (2.4) | 1640 (1.6) |
Cisgender | 89 776 (97.6) | 103 797 (98.4) |
AMAB adolescents, n (%) | ||
Transgender | 1285 (2.8) | 866 (1.7) |
Cisgender | 43 848 (97.2) | 50 618 (98.3) |
AFAB adolescents, n (%) | ||
Transgender | 876 (1.9) | 774 (1.4) |
Cisgender | 45 928 (98.1) | 53 179 (98.6) |
Sex assigned at birth ratio, transgender AMAB:transgender AFAB | 1.5:1 | 1.2:1 |
Additionally, TGD youth were significantly more likely to be victims of school bullying and electronic bullying when compared with cisgender sexual minority youth, who themselves were more likely to be victims of these types of bullying when compared to cisgender heterosexual youth (Tables 3 and 4).
YRBS Year . | 2017 . | 2019 . | ||||
---|---|---|---|---|---|---|
. | Cisgender Sexual Minority, n (%) . | Transgender and Gender Diverse, n (%) . | P . | Cisgender Sexual Minority, n (%) . | Transgender and Gender Diverse, n (%) . | P . |
School bullying | 2034 (30.5) | 675 (38.7) | <.001 | 2515 (28.7) | 567 (45.4) | <.001 |
Electronic bullying | 2213 (26.7) | 628 (32.2) | <.001 | 2577 (24.1) | 573 (37.5) | <.001 |
YRBS Year . | 2017 . | 2019 . | ||||
---|---|---|---|---|---|---|
. | Cisgender Sexual Minority, n (%) . | Transgender and Gender Diverse, n (%) . | P . | Cisgender Sexual Minority, n (%) . | Transgender and Gender Diverse, n (%) . | P . |
School bullying | 2034 (30.5) | 675 (38.7) | <.001 | 2515 (28.7) | 567 (45.4) | <.001 |
Electronic bullying | 2213 (26.7) | 628 (32.2) | <.001 | 2577 (24.1) | 573 (37.5) | <.001 |
YRBS Year . | 2017 . | 2019 . | ||||
---|---|---|---|---|---|---|
. | Cisgender Heterosexual, n (%) . | Cisgender Sexual Minority, n (%) . | P . | Cisgender Heterosexual, n (%) . | Cisgender Sexual Minority, n (%) . | P . |
School bullying | 10 296 (17.1) | 2034 (30.5) | <.001 | 12 077 (16.6) | 2515 (28.7) | <.001 |
Electronic bullying | 10 426 (13.5) | 2213 (26.7) | <.001 | 11 729 (13.4) | 2577 (24.1) | <.001 |
YRBS Year . | 2017 . | 2019 . | ||||
---|---|---|---|---|---|---|
. | Cisgender Heterosexual, n (%) . | Cisgender Sexual Minority, n (%) . | P . | Cisgender Heterosexual, n (%) . | Cisgender Sexual Minority, n (%) . | P . |
School bullying | 10 296 (17.1) | 2034 (30.5) | <.001 | 12 077 (16.6) | 2515 (28.7) | <.001 |
Electronic bullying | 10 426 (13.5) | 2213 (26.7) | <.001 | 11 729 (13.4) | 2577 (24.1) | <.001 |
Discussion
Using a national sample of United States adolescents, we found that there were more TGD AMAB adolescents than TGD AFAB adolescents in both 2017 and 2019. Additionally, the total percentage of TGD adolescents in our sample decreased from 2.4% in 2017 to 1.6% in 2019. This decrease in the overall percentage of adolescents identifying as TGD is incongruent with an ROGD hypothesis that posits social contagion.
The AMAB:AFAB ratio, still in favor of more TGD AMAB participants for both years, shifted slightly toward TGD AFAB participants from 2017 to 2019. Importantly, this change was due to a reduction in the number of TGD AMAB participants, rather than an increase in TGD AFAB participants, again arguing against a notion of social contagion with unique susceptibility among AFAB youth.
Moreover, we found that TGD youth were more likely to be victims of bullying and to have attempted suicide when compared with cisgender youth, which is consistent with past studies.1 Our additional analyses reveal that TGD youth experience significantly higher rates of bullying than cisgender sexual minority youth, who themselves experience significantly higher rates of bullying when compared with cisgender heterosexual youth (Tables 3 and 4). These exceptionally high rates of bullying among TGD youth are inconsistent with the notion that young people come out as TGD either to avoid sexual minority stigma or because being TGD will make them more popular among their peers, both of which are explanations that have recently been propagated in the media.11 Of note, a substantial percentage of TGD adolescents in the current study sample also identified as gay, lesbian, or bisexual with regard to their sexual orientation (Table 1), which further argues against the notion that adopting a TGD identity is an attempt to avoid sexual minority stigma.
The deleterious effect of unfounded hypotheses stigmatizing TGD youth, particularly the ROGD hypothesis, cannot be overstated, especially in current and longstanding public policy debates. Indeed, the notion of ROGD has been used by legislators to prohibit TGD youth from accessing gender-affirming medical care, despite the considerable methodological limitations underlying the generation of this hypothesis, as well as the unequivocal support for gender-affirming medical care by multiple major medical organizations, including the American Medical Association, the American Academy of Pediatrics, the American Academy of Child & Adolescent Psychiatry, and the American Psychiatric Association.8 Multiple studies have revealed that prohibiting TGD adolescents from accessing gender-affirming medical care would be expected to have detrimental impacts on TGD youth wellbeing.16–18,22 The current study adds to the extant research arguing against the ROGD hypothesis by providing evidence inconsistent with the theories that (1) social contagion drives TGD identities, with unique susceptibility among AFAB youth, and (2) that youth identify as TGD due to such identities being less stigmatized than cisgender sexual minority identities.
Limitations of this study include that data were collected through a school-based survey; therefore, TGD youth who do not attend school were not represented. Additionally, all participants included in this study lived in states that administered the YRBS gender identity question, thus TGD youth in other states are not represented. Moreover, the question through which the sex of participants was ascertained did not use the established 2-step method of asking about gender identity.19 Although our results should be understood in the context of this limitation, we posit that TGD youth are likely able to accurately differentiate between sex and gender identity, given that these characteristics are foundationally salient to their identities. Indeed, several studies found that TGD youth seem to accurately navigate the differences between their sex assigned at birth and gender identity.13,14,15 Moreover, it is unlikely that the proportion of youth who answered the sex question based on their gender identity would differ by sex assigned at birth. Thus, the ratio of youth by sex assigned at birth is likely to be largely unaffected.19 Future studies could use the 2-step method of determining gender identity to more accurately capture subgroup characteristics by sex assigned at birth and gender,19 although we also acknowledge that best practices for gender identity data collection are iterative and ever-evolving.15,20,21,23
Conclusions
By examining the AMAB:AFAB ratio of TGD adolescents across 16 states in 2017 and 2019, our findings are in direct contrast with central components of the ROGD hypothesis, as well as previous studies that used smaller samples from single clinics.9,10 The AMAB:AFAB ratio of TGD adolescents in the United States does not appear to favor TGD AFAB adolescents, and the notion of ROGD should not be used to restrict the provision of gender-affirming medical care for TGD adolescents. Results from this study also argue against the notions that TGD youth come to identify as TGD because of social contagion or to flee stigma related to sexual minority status.
Acknowledgments
We thank the YRBS adolescent participants and local education agencies for their continuous engagement in population health research.
Dr Turban conceptualized and designed the study and conducted the initial analyses; Brett Dolotina provided administrative support, assisted with initial analyses, and drafted the initial manuscript; Dana King coordinated data acquisition and assisted with initial analyses; Dr Keuroghlian supervised all phases of this study; and all authors critically reviewed and revised the manuscript for intellectual content, approved the final manuscript as submitted, and agree to be accountable for all aspects of the work.
FUNDING: All phases of this study were supported by R25 grant MH094612 from The National Institute of Mental Health (Dr Turban) and by The Sorensen Foundation (Dr Turban). The funders had no role in the design and conduct of the study.
CONFLICT OF INTEREST DISCLOSURES: Dr Turban reports receiving textbook royalties from Springer Nature and expert witness payments from the American Civil Liberties Union and Lambda Legal. He has received a pilot research award for general psychiatry residents from the American Academy of Child & Adolescent Psychiatry and its industry donors (Arbor and Pfizer) and a research fellowship from the Sorensen Foundation. Dr Keuroghlian reports receiving textbook royalties from McGraw Hill.
Comments
In Reply: Sex Assigned at Birth Ratio among Transgender and Gender Diverse Adolescents in the United States
We appreciate the interest in our recent study regarding the sex assigned at birth ratio among transgender and gender diverse (TGD) adolescents in the United States[1] from Lett et al.[2] and others who have shared their online comments.
We agree with Lett et al. that the notion of “social contagion” is a gross misrepresentation of TGD communities’ social support, cohesiveness, and connectedness. Through our experience and expertise as gender-affirming care providers, as well as the lived TGD experience and community engagement within our authorship team, we are deeply aware that TGD youth seek out support and knowledge from peers about gender and health as part of their developmental milestones and resiliency.
Our article’s introduction explains the specific questions we studied regarding the notion of social contagion for TGD identities, including the premise that adolescents assigned female sex at birth would be more susceptible to this phenomenon:
“A recent descriptive article hypothesized the existence of a new subtype of gender dysphoria, putatively termed “rapid-onset gender dysphoria” (ROGD). The ROGD hypothesis asserts that young people begin to identify as TGD for the first time as adolescents rather than as prepubertal children and that this identification and subsequent gender dysphoria are the result of social contagion. This hypothesis further asserts that youth assigned female sex at birth (AFAB) are more susceptible to social contagion than those assigned male sex at birth (AMAB), with a resultant expectation of increasing overrepresentation of TGD AFAB youth relative to TGD AMAB youth.”
We would emphasize again that we are not proponents of ROGD or social contagion hypotheses. We did not adopt ROGD or social contagion as our study’s “lens.” Rather, we sought to empirically evaluate specific ideas that have been propagated as a result of these hypotheses. The conceptual link between the sex assigned at birth ratio and social contagion has been explicitly cited in recent political debates, including in expert witness testimony in Brandt v Rutledge, a case in Arkansas regarding the state’s law that would ban gender-affirming medical care for adolescents,[3] despite opposition from all major medical organizations, including The American Academy of Pediatrics.[4] Given this, we maintain that the theoretical basis for our study is both sound and relevant.
Lett et al. state that our study performed a trend analysis based on only two time points. We would point out that we do not refer to a ‘trend’ or a ‘trend analysis’ in the article, which contains no claim beyond the findings in 2017 and 2019. We did not extrapolate beyond these two years. The primary question of this study was the sex assigned at birth ratio among TGD adolescents, which we found to favor TGD adolescents assigned male sex at birth in both 2017 and 2019. While the data from 2017 and 2019 could be combined to yield the same result, we presented the data from each of these two years separately for clarity and transparency.
Lett et al. also commented that we did not utilize Youth Risk Behavior Survey (YRBS) sample weights in our analyses. The YRBS methodology document describes the two-stage, cluster sample design to produce a representative sample within each jurisdiction.[5] The survey weights provided are for student nonresponse and the distribution of students by grade, sex, and race/ethnicity in each jurisdiction.[5][ However, no specific information is available for how the weights are calculated, and no external benchmarks are cited. With few data sources including gender identity information and no external benchmarks for whether TGD youth are more or less likely to respond, we intentionally opted to present unweighted results transparently.
Here we present additional analyses using the YRBS weights, as we believe the results may be of interest to readers. Table 1 below mirrors Table 2 from our original article, this time using the survey weights. With this weighted analytic approach, the sex assigned at birth ratio again favors TGD adolescents assigned male sex at birth in both 2017 and 2019, as we had found in the unweighted analyses.
Tables 2 and 3 below present analyses corresponding to those in Tables 3 and 4 of our original study, now using the YRBS weights. Our original findings are largely replicated by this additional analytic approach. In 2019, TGD adolescents faced significantly elevated rates of school and electronic bullying victimization when compared to cisgender sexual minority adolescents, who themselves faced significantly higher rates of school and electronic bullying victimization when compared to cisgender heterosexual adolescents. Using YRBS weights, the results comparing TGD adolescents to cisgender sexual minority adolescents in 2017 are not statistically significant, though they are in the same direction as the corresponding unweighted analyses. The purpose of this comparison in our study was to assess whether TGD youth report lower rates of victimization than cisgender sexual minority youth, a notion that has been proposed by others. Given that this is not the case even with application of YRBS weights, the findings from these additional, weighted analyses remain aligned with the overall conclusion of our study.
Lett et al. highlighted that different states were included in our analyses for 2017 and 2019. This is because not all states collected gender identity data in both years. Table 4 below presents the sex assigned at birth ratios with inclusion of only the nine states that collected data in both 2017 and 2019. The sex assigned at birth ratio again favors TGD adolescents assigned male sex at birth in both 2017 and 2019. We repeated these nine-state analyses applying the YRBS weights, and the resulting sex assigned at birth ratios were 1.19 in 2017 and 1.16 in 2019, again favoring TGD adolescents assigned male sex at birth in both years. Prior to receiving the comment by Lett et al. from the journal, we had informed the journal of a typo in footnote A of Table 1 that incorrectly listed states that collected gender identity in 2017; this has been corrected.
We would further highlight that even if the YRBS weighting methods were valid for TGD youth, employing the state-level weights would not produce a nationally representative sample. Contrary to the implication by Lett et al., we do not make the claim of a nationally representative sample in the study, and we chose to combine all available data to include the responses of as many TGD youth as possible. Our article’s limitations section reads: “Additionally, all participants included in this study lived in states that administered the YRBS gender identity question, thus TGD youth in other states are not represented.” The article does not claim that results are generalizable to the entire United States.
We agree with Lett et al. that a nationally representative sample would be ideal for these analyses; those data do not yet exist. We have previously published on existing datasets that are available to study TGD health, describing their various strengths and limitations.6 Nevertheless, we believe that our approach involving existing samples is reasonable, that we have not overinterpreted findings, and that the study adds value to the existing literature. We note that non-probability samples are essential for studying minoritized populations.[6-8]
We agree with Lett et al. that different policy and social climates across states could impact how comfortable youth are disclosing TGD identities. For example, youth may feel more comfortable disclosing TGD identities in more accepting sociopolitical environments, such as states the U.S. Northeast, which are overrepresented among the states sampled by this study. We included these states because they are the ones that collected gender identity data, not because of their sociopolitical environments. That being said, some have claimed that adolescents in states with more accepting social environments are more susceptible to so-called social contagion. If this were true, based on the notion of social contagion one might expect that our study’s overrepresentation of Northeastern states, which are generally more accepting of TGD youth, would result in a sex assigned at birth ratio favoring TGD adolescents assigned female sex at birth, which was not the case in our findings.
Lett et al. present state-level data for the sex assigned at birth ratio in their letter. As they point out, many of these state-level ratios are not particularly informative, as they are based on small sample sizes (e.g., they cite instability in the data from Rhode Island). This is the reason we did not examine state-level ratios. They also present a sensitivity analysis in which they exclude data from Maryland. The results of their sensitivity analysis align with our study’s conclusions: that the sex assigned at birth ratio favored youth assigned male sex at birth in both 2017 and 2019.
Some online comments have mentioned that the YRBS does not use a 2-step question for gender identity collection, a point that we also discussed as a limitation in our article. We are hopeful that future large-scale survey studies like the YRBS will improve gender identity data collection to align with current recommended practices.[9] One citation we provided in our discussion of this was a study by Kidd et al. that asked adolescents about both their gender identity and their sex assigned at birth in a 2-step question.[10] Kidd et al. utilized a regionally modified YRBS in a Northeastern midsized city school district comprised of 13 high schools, with data collection taking place in 2018, the year between our study’s two years of data collection. In examining data from that study, which utilized a 2-step question, the AMAB:AFAB ratio is 1.3, similar to that in our study. The 2-step question appears to be more sensitive (i.e., captures more TGD participants), but it does not appear to substantially impact the sex assigned at birth ratio, in line with Kidd et al.’s finding that similar proportions of TGD adolescents assigned female sex at birth and TGD adolescents assigned male sex at birth labeled their sex as their gender identity.10
While the sex assigned at birth ratio from the Kidd et al. study is in line with our study’s findings, we fully agree with the online comments that the way in which the YRBS collects sex assigned at birth and gender identity data is imperfect and would be improved by using current recommended practices. Gender identity data collection is an evolving area of epidemiologic research, where recommended practices continue to change as we strive for greater accuracy and cultural responsiveness. We disagree, however, with the idea that clinic-collected data represent the broader TGD population, a point that has been discussed by others in regard to the literature on the sex assigned at birth ratio.[11]
In summary, we appreciate the interest in our article that led us to share these additional analyses, showing that the original findings are robust across analytic approaches. We are glad that Lett et al. re-emphasized two important points we made in the original article: (1) that not all states collect gender identity data as part of their YRBS, and that such data are vital and should be collected by all states, and (2) that all states should collect gender identity data by using current recommended practices, with inclusion of TGD voices throughout this decision-making process.
REFERENCES
1. Turban JL, Dolotina B, King D, Keuroghlian AS. Sex Assigned at Birth Ratio Among Transgender and Gender Diverse Adolescents in the United States. Pediatrics. 2022; e2022056567.
2. Lett E, Everhart AR, Streed C, Restar A. Science and Public Health as a Tool for Social Justice Requires Methodological Rigor: A Response to Turban et al.“Sex Assigned at Birth Ratio Among Transgender and Gender Diverse Adolescents in the United States”. 2022.
3. Levine S. Expert Declaration in Dylan Brandt et al. v Leslie Rutledge et al. 2022. Available at: https://www.aclu.org/sites/default/files/field_document/045-1_stephen_levine_declaration.pdf. Accessed: August 20, 2022.
4. Turban JL, Kraschel KL, Cohen IG. Legislation to Criminalize Gender-Affirming Medical Care for Transgender Youth. JAMA. 2021;325(2):2251-2252.
5. Brener ND, Kann L, Shanklin S, et al. Methodology of the youth risk behavior surveillance system—2013. Morbidity and Mortality Weekly Report: Recommendations and Reports. 2013;62(1):1-20.
6. Turban JL, Almazan AN, Reisner SL, Keuroghlian AS. The Importance of Non-Probability Samples in Minority Health Research: Lessons Learned from Studies of Transgender and Gender Diverse Mental Health. Transgender Health. 2022.
7. King WM, Restar A, Operario D. Exploring multiple forms of intimate partner violence in a gender and racially/ethnically diverse sample of transgender adults. Journal of Interpersonal Violence. 2021;36(19-20):NP10477-NP10498.
8. Lett E, Abrams MP, Gold A, Fullerton F-A, Everhart A. Ethnoracial inequities in access to gender-affirming mental health care and psychological distress among transgender adults. Social Psychiatry and Psychiatric Epidemiology. 2022;57(5):963-971.
9. Goldhammer H, Grasso C, Katz-Wise SL, Thomson K, Gordon AR, Keuroghlian AS. Pediatric sexual orientation and gender identity data collection in the electronic health record. Journal of the American Medical Informatics Association. 2022;29(7):1303-1309.
10. Kidd KM, Sequeira GM, Rothenberger SD, et al. Operationalizing and analyzing 2-step gender identity questions: Methodological and ethical considerations. Journal of the American Medical Informatics Association. 2022;29(2):249-256.
11. Ashley F. Shifts in assigned sex ratios at gender identity clinics likely reflect changes in referral patterns. The Journal of Sexual Medicine. 2019;16(6):948-949.
Table 1. Percentages of TGD and Cisgender Adolescents by YRBS Year and Sex Assigned at Birth (Weighted Analyses)
YRBS Year
2017
2019
All adolescents
TGD
1.8%
1.6%
Cisgender
98.2%
98.4%
AMABadolescents
TGD
2.0%
1.7%
Cisgender
98.0%
98.3%
AFABadolescents
TGD
1.7%
1.5%
Cisgender
98.3%
98.5%
Sex Assigned At Birth Ratio(% Adolescents AMAB Who Are TGD: % Adolescents AFAB Who Are TGD)
1.2:1
1.1:1
Abbreviations: AMAB: assigned male sex at birth, AFAB: assigned female sex at birth, TGD: transgender and gender diverse, YRBS: Youth Risk Behavior Survey.
Table 2. Comparison of Bullying Rates Between TGD Youth and Cisgender Sexual Minority Youth (Weighted Analyses)
YRBS Year
2017
2019
Cisgender Sexual Minority
Transgender and Gender Diverse
Cisgender Sexual
Minority
Transgender and Gender Diverse
(%)
(%)
p
(%)
(%)
p
School bullying
30.0%
36.6%
.06
26.8%
44.8%
<.0001
Electronic bullying
26.8%
29.1%
.55
23.8%
33.6%
.0001
Abbreviation: TGD: transgender and gender diverse.
Table 3. Comparison of Bullying Rates Between Cisgender Heterosexual Youth and Cisgender Sexual Minority Youth (Weighted Analyses)
YRBS Year
2017
2019
Cisgender Heterosexual
Cisgender Sexual Minority
Cisgender Heterosexual
Cisgender Sexual Minority
(%)
(%)
p
(%)
(%)
p
School bullying
17.6%
30.0%
<.0001
15.7%
26.8%
<.0001
Electronic bullying
14.3%
26.8%
<.0001
12.5%
23.8%
<.0001
Abbreviations: TGD: transgender and gender diverse, YRBS: Youth Risk Behavior Survey.
Table 4. Examining the Sex Assigned at Birth Ratio among States that Collected Gender Identity Data in both 2017 and 2019 (Unweighted Analyses)
State
AMAB 2017
AFAB 2017
Ratio 2017
AMAB 2019
AFAB 2019
Ratio 2019
Colorado
6
9
10
7
Hawaii
97
47
33
37
Maine
78
79
65
64
Maryland
881
542
342
278
Michigan
8
14
30
36
Rhode Island
17
22
12
4
Vermont
124
115
143
138
Wisconsin
22
15
7
12
Massachusetts
34
21
21
18
Total
1267
864
1.47
663
594
1.12
Abbreviations: AMAB: assigned male sex at birth, AFAB: assigned female sex at birth.
Deeply flawed and erroneous conclusions from a limited dataset
In conducting our analyses, our multidisciplinary team sedulously considered the non-random sampling of the population queried about transgender identity, the information not solicited in the survey, the wording and possible interpretations of the questions, as well as the accuracy and completeness of the data generated. We acknowledged multiple limitations due to the imprecise wording of several questions regarding self-identity and sexuality. Turban et al., on the other hand, assume away the key question of how trans-identified teens will answer “What is your sex?” by arguing for the “foundational salience” of biological sex. They cite three references that do nothing to substantiate their statement and ignore CDC documentation urging caution in interpreting the “sex” variable. They are oblivious to the missingness of this variable being a clue as to how it may be read by transgender-identified students who are 15 times more likely to leave it blank than chance.
Turban et al. draw several conclusions that are simply flawed given the limitations of the survey. In particular, we note the following concerns:
Their findings are in marked contrast to the internationally recognized phenomenon of a reversal in the sex ratio of adolescents presenting at gender clinics reported by multiple authors in settings where natal sex has been accurately documented;
They fail to utilize the sampling weights included with the YRBSS data which invalidates any conclusions they make regarding the overall trend in transgender identification in 2017 and 2019;
A population-level sex ratio that does not favor females (although this is not what they actually calculated given their failure to use sampling weights and the fact that the questions of interest were not asked across the U.S.) would not undermine the social contagion element of the ROGD hypothesis, as relative growth rates of transgender identification between the sexes over the past decade cannot be determined from their analyses;
Examination of data over two points in time does not represent a trend;
A dataset with no information about the timing of transgender identification relative to puberty, friends’ transgender identification, or online activity can neither refute nor confirm the hypothesis that ROGD is a significant driver of the sharp increase in transgender identification;
The survey provides no information regarding mental health comorbidities, a critical element of the ROGD hypothesis.
The authors’ assumptions and specious conclusions almost completely disregard the obvious limitations of the dataset, and they add to these problems with unforced methodological errors. Overall, this paper is a disservice to the debate on the etiology of adolescent-onset gender dysphoria.
My Clinical Experience Contradicts The Claims of Turban et al. in "Sex Assigned at Birth Ratio among Transgender and Gender Diverse Adolescents in the United States"
As we know from gender clinic data the world over, the number of adolescents presenting at such centers for treatment has skyrocketed over the past decade. For example, the Gender Identity Development Service in the UK saw referrals double between 2015 and 2016, with 50% increases in the years prior. Similar increases have been noted in Finland, Norway, the Netherlands, Canada, and Australia.
Meanwhile, my inbox and those of my colleagues working on this issue are filled with emails from families seeking therapists for their newly gender dysphoric adolescent. These emails tell strikingly similar stories – children with no early history of any gender distress or incongruence who announced a new identity, often after spending time online consuming trans content or having one or more friends come out as trans.
The detransitioners I have worked with share personal stories that corroborate the hypothesis that peer and social media influence may play a role in the development of a trans identity. They report having a best friend come out as trans before they did or spending hours every day on sites such as Tumblr or YouTube. Most describe experiencing serious mental health issues prior to coming out as trans, including eating disorders, obsessive compulsive disorder, and depression.
I agree that we do not have conclusive proof that peer and social media influence are part of the equation, but we also don’t have evidence that they are not. Given the high stakes nature of the medical interventions that are often sought by young people identifying as trans, this area of medicine needs more good quality research.
Lisa Marchiano, LCSW
McCall, B. (2021, April 23). Transition therapy for transgender teens drives divide. WebMD. Retrieved August 14, 2022, from https://www.webmd.com/children/news/20210427/transition-therapy-for-transgender-teens-drives-divide
NHS. (2019, June 28). Referrals to the Gender Identity Development Service (GIDS) level off in 2018-19. NHS choices. Retrieved August 14, 2022, from https://tavistockandportman.nhs.uk/about-us/news/stories/referrals-gender-identity-development-service-gids-level-2018-19/
The Data Fail to Support the Claims in Turban et al., “Sex Assigned at Birth Ratio among Transgender and Gender Diverse Adolescents in the United States.”
First, for Turban et al. to support or refute the possibility of social contagion for gender dysphoria in youth, they would have had to use a dataset that collected information about the relationships between participants and to have examined the pattern of distribution for gender dysphoria cases to determine if there was a presence or absence of clustering. Fluctuations in the overall rates of a condition, which they based their faulty conclusions on, are irrelevant to whether social contagion is or is not occurring, particularly in pockets of youth networks.
Second, the study was not equipped to evaluate any of the ROGD hypotheses. Briefly, the ROGD hypotheses pertain to youth with late-onset gender dysphoria and posit that social influences (including social contagion and peer contagion), mental health conditions, trauma, difficulty accepting oneself as lesbian, gay or bisexual (LGB), and other psychosocial factors can contribute the development of gender dysphoria in some individuals2,3. The YRBS did not collect information about the timing of participant onset of gender dysphoria in relation to puberty. It does not contain any data about comorbid mental health diagnoses or autism spectrum conditions. As these are key elements of the ROGD hypotheses, the evidence provided in the paper is weak to the point of being inconsequential.
Third, the authors claim that their results of higher rates of bullying for TGD youth than LGB (non-transgender) youth contradict the possibility that stigma about being lesbian, gay, or bisexual could contribute to youth becoming gender dysphoric or transgender-identified. Being bullied is not the same thing as experiencing stigma. Even people who have not been bullied can experience stigma for being lesbian, gay, or bisexual. Therefore, the study does not address nor can it argue for or against whether stigma or difficulty accepting oneself as LGB can contribute to gender dysphoria or transgender identification.
Finally, high-quality data from gender clinics worldwide demonstrate striking changes in the demographics of adolescent patient populations including a shift to sex ratios that favor natal females.4–7 The absence of a female predominant sex ratio in the unweighted YRBS sample of transgender-identified teens does not negate this fact. There is reason to doubt the reliability of the sex ratio reported by Turban et al., as a known limitation of the YRBS is that the “What is your sex?” question may be interpreted inconsistently by transgender-identified youth8. Further, the ROGD hypotheses have no requirement that all samples of gender dysphoric youth must favor natal females and thus, the sex ratio reported by Turban et al. can neither support nor refute the ROGD hypotheses.
While the study reveals some interesting findings, due to the design and dataset, it cannot provide any meaningful information about social contagion or the ROGD hypotheses. That the authors claim otherwise is deeply misleading.
References
1. Turban JL, Dolotina B, King D, Keuroghlian AS. Sex Assigned at Birth Ratio Among Transgender and Gender Diverse Adolescents in the United States. Pediatrics. Published online August 3, 2022:e2022056567. doi:10.1542/peds.2022-056567
2. Littman L. Parent reports of adolescents and young adults perceived to show signs of a rapid onset of gender dysphoria. Romer D, ed. PLOS ONE. 2018;13(8):e0202330. doi:10.1371/journal.pone.0202330
3. Littman L. Individuals Treated for Gender Dysphoria with Medical and/or Surgical Transition Who Subsequently Detransitioned: A Survey of 100 Detransitioners. Arch Sex Behav. 2021;50(8):3353-3369. doi:10.1007/s10508-021-02163-w
4. Aitken M, Steensma TD, Blanchard R, et al. Evidence for an altered sex ratio in clinic‐referred adolescents with gender dysphoria. J Sex Med. 2015;12(3):756-763. doi:10.1111/jsm.12817
5. de Graaf NM, Giovanardi G, Zitz C, Carmichael P. Sex ratio in children and adolescents referred to the Gender Identity Development Service in the UK (2009–2016). Arch Sex Behav. 2018;47(5):1301-1304. doi:10.1007/s10508-018-1204-9
6. Kaltiala-Heino R, Sumia M, Työläjärvi M, Lindberg N. Two years of gender identity service for minors: overrepresentation of natal girls with severe problems in adolescent development. Child Adolesc Psychiatry Ment Health. 2015;9(1):9. doi:10.1186/s13034-015-0042-y
7. Kaltiala R, Bergman H, Carmichael P, et al. Time trends in referrals to child and adolescent gender identity services: a study in four Nordic countries and in the UK. Nord J Psychiatry. 2020;74(1):40-44. doi:10.1080/08039488.2019.1667429
8. Johns MM, Lowry R, Andrzejewski J, et al. Transgender Identity and Experiences of Violence Victimization, Substance Use, Suicide Risk, and Sexual Risk Behaviors Among High School Students — 19 States and Large Urban School Districts, 2017. MMWR Morb Mortal Wkly Rep. 2019;68(3):67-71. doi:10.15585/mmwr.mm6803a3
Science and Public Health as a Tool for Social Justice Requires Methodological Rigor: A Response to Turban et al. “Sex Assigned at Birth Ratio Among Transgender and Gender Diverse Adolescents in the United States”
1. Center for Applied Transgender Studies, Chicago, IL
2. Computational Health Informatics Program, Boston Children’s Hospital, Boston, MA
3. Perelman School of Medicine, Philadelphia, PA
4. University of Michigan School of Information, Ann Arbor, MI
5. Department of Health Behavior & Health Education ,University of Michigan School of Public Health, Ann Arbor, MI
6. Section of General Internal Medicine, Department of Medicine, Boston University School of Medicine, Boston, MA
7. Center for Transgender Medicine and Surgery, Boston Medical Center, Boston, MA
8. Department of Epidemiology, University of Washington School of Public Health, Seattle, WA
9. Department of Social and Behavioral Sciences, Yale University School of Public Health, New Haven, CT
We write, as scientists, methodologists, and clinicians working in gender-affirming care, our views to the recent article published in Pediatrics by Turban and colleagues, who also argue for better provision of healthcare for transgender and nonbinary (trans) youths.1 The authors utilized the Youth Risk Behavior Surveillance System (YRBSS) to examine the social contagion hypothesis of the unsubstantiated claim of rapid-onset gender dysphoria. While we agree with the authors’ conclusion that social contagion rhetoric should not be used to politically and medically argue against the provision of care for trans adolescents – as currently reflected and weaponized with several anti-trans policies in the US banning gender-affirming medical care2,3 – we examined cautiously the study’s premise and analytical design, and identified critical theoretical and methodological concerns specific to its conceptualization of social contagion and its data analysis.
Foremost, in alignment with several bodies of major medical organizations, we assert that transphobia is a social contagion, and being transgender is not. Turban et al.’ sex-assigned ratio analysis draws in on Littman’s misconceptualized social contagion hypothesis, which was operationalized as parents’ observation of their trans kid having at least one trans friend in their peer group, and occured more among parents with trans kids assigned female at birth (AFAB) than male assigned at birth (AMAB).4 The premise of social contagion hypothesis is a gross misinterpretation of trans communities’ social support, cohesiveness, and connectedness. Indeed, it is well-documented that trans youths, when asked directly, seek out support and knowledge from peers about gender and health as part of their developmental milestones and resiliency5. In addition, conducting analysis based on sex-assigned AMAB:AFAB-ratio is not conceptually a direct disconfirmation of the premise in the study by Littman given the significant recruitment bias that yielded a skewed study sample of mostly parents of AFAB trans kids. As such, the very phenomenon that is being interrogated by Turban et al.; the presence of a biased AMAB:AFAB-ratio, is an artifact of a flawed study design, rather than a true, verifiable component of the supposed theory. Therefore, researchers and policymakers’ continued use of social contagion as a lens to account for trans youths’ connectedness with each other rests on misguided practice of theorizing, hypothesis testing, and legislating.
To assess the validity of the ROGD hypothesis Turban et al. perform a trend analysis to provide point estimates of AFAB and AMAB trans youth nationally based on a set of samples from a subset of states. Unfortunately, there are serious threats to validity of both the trend analysis and the estimates of AFAB and AMAB youth. For the former, the trend analysis is based only on two time points, which is insufficient to provide robust interpretation, let alone a trend. Also unfortunate, is the study’s data reporting error that severely misrepresents the robustness of the sample. Turban et al. state that their estimates of the AMAB:AFAB-ratio are based on 16 states in the abstract, 15 for 2017 and 15 for 2019 (Delaware in 2017 only and New Jersey in 2019 only) as shown in the caption for Table 1. However, only 10 states fielded the SOGI module in 2017,6 and of them only 9 had publicly available data (Massachusetts does not provide permission for the CDC to share their data).7 Similarly, only 14 states with publicly available data fielded the SOGI module in 2019. Under these circumstances, the trend analysis is comparing subsets of trans youth from different states and any differences are likely due to sampling bias making the trend analysis invalid.
Beyond issues with the trend analysis are issues with the individual point estimates for the AMAB:AFAB-ratio. For 2017 and 2019 less than one-fifth and one-fourth, respectively, of the 50 states and five territories in the United States are included in the analysis. Table 1 shows the high variability of the AMAB:AFAB-ratio between states and within states across time points. Much of this variability is driven by the sample size; for instance, in the Rhode Island sample between 2017 and 2019 the AMAB:AFAB-ratio inverted from 0.8 to 3.0, based on TGD youth samples of only 39 and 16 persons, respectively. In comparison to Rhode Island, Maryland dominates the sample for both years. Specifically, Maryland comprises 67% of the sample (1547/2302 persons) in 2017, and 40% (711/1790 person) in 2019. To show the sensitivity to state inclusion, we recalculated the AMAB:AFAB-ratio without that state for 2017 and 2019, and found 1.2 and 1.1, respectively compared to the 1.5 and 1.2 in the authors original analysis. Because the authors methodology did not account for oversampling, their analysis provided biased results and shifted the “national” estimate that is driven by a single state. Additionally, the analysis neglects the survey sampling design. YRBSS state surveys are two-stage cluster samples and the data include weights that allow for state-level representative analyses. We have written elsewhere that such analyses are suboptimal for estimating transgender populations when one-step gender identity measurements are used,8 however; to overlook the sampling schema precludes the possibility of state-level representative estimates, making further extrapolation to the entire US dubious. This critique also applies to the pairwise comparative analyses in Tables 2 and 3 between trans, cisgender sexual minority, and cisgender heterosexual youth which similarly fail to account for survey sampling design and clustering by state. Providing details of any approach regarding accounting of sampling schema, if any were indeed utilized, would have benefitted the analysis. Lastly, the analysis becomes more problematic when one notes that the few states included are not a random sample of the US states and territories, but instead show a concentration of states in the Northeast, and a smaller group in the Midwest with remaining states having no neighbors that also collected data on TGD youth. There are state-level variations in policy climates for transgender youth in school9–11 that would facilitate or prohibit their inclusion in the sampling frame for a given state. With the overrepresentation of Northeastern states, and the exclusion of most Southern and Midwestern states, the approach used here cannot reliably provide national estimates that incorporate regional variation in policy climes.
We applaud the authors for their approach to address the deleterious and unsubstantiated rhetoric of the anti-transgender movement. Many of the challenges that we identified are not specific to the authors but represent challenges facing all researchers, trans and cis, working in transgender health who are forced to work with suboptimal data sources that lack inclusion of transgender persons or fail to use best practices for gender identity ascertainment. 12 However, science and public health as a tool of social justice requires methodological rigor in addition to conviction and intent. While this study was admirable, we find that the results were overinterpreted and that the theoretical and methodological shortcomings of the article run the risk of being more harmful than supportive. A more productive pursuit is the continued advocacy of methods development to ascertain gender identity, comprehensive inclusion of transgender individuals in survey design and sampling strategies, and increased funding for prospective and truly representative datasets to answer these questions with high-quality and methodologically sound research studies. In the absence of more and better data, studies like this one create methodological problems for future scientists to correct rather than allowing the science to scaffold toward a more just and equitable future for trans youth, and indeed trans communities generally.
Table 1: State Breakdown of Data Availability and AMAB:AFAB-Ratio among States with Public YRBSS Data
State
2017 AMAB:AFAB (ratio)
N=2302
2019 AMAB: AFAB (ratio)
N=1790
Colorado (CO)
6:9 (0.7)
10:7 (1.4)
Delaware (DE)
18:12 (1.5)
--
Florida (FL)
--
33:41 (0.8)
Hawaii (HI)
97:47 (2.1)
33:37 (0.9)
Maine (ME)
78:79 (1)
65:64 (1)
Maryland (MD)
881:542 (1.6)
342:278 (1.2)
Michigan (MI)
8:14 (0.6)
30:36 (0.8)
Nevada (NV)
--
9:13 (0.7)
New Jersey (NJ)
--
4:5 (0.8)
New York (NY)
--
113:77 (1.5)
Pennsylvania (PA)
--
8:14 (0.6)
Rhode Island (RI)
17:22 (0.8)
12:4 (3)
Vermont (VT)
124:115 (1.1)
143:138 (1)
Virginia (VA)
--
36:30 (1.2)
Wisconsin (WI)
22:15 (1.5)
7:12 (0.6)
Overall
1251:855 (1.46)
845:756 (1.12)
Excluding Maryland
370:313 (1.18)
503:478 (1.05)
“--” indicates that state did not field the SOGI module during that year
Note: Massachusetts does not provide permission for the CDC to share their data.
References
1. Turban JL, Dolotina B, King D, Keuroghlian AS. Sex Assigned at Birth Ratio Among Transgender and Gender Diverse Adolescents in the United States. Pediatrics. Published online August 3, 2022:e2022056567. doi:10.1542/peds.2022-056567
2. The Florida Health Department. Treatment of Gender Dysphoria for Children and Adolescnts. Accessed August 4, 2022. https://www.floridahealth.gov/newsroom/2022/04/20220420-gender-dysphoria-guidance.pr.html
3. Movement Advancement Project | Healthcare Laws and Policies. Accessed August 4, 2022. https://www.lgbtmap.org/equality-maps/healthcare_laws_and_policies/youth_medical_care_bans
4. Restar AJ. Methodological Critique of Littman’s (2018) Parental-Respondents Accounts of “Rapid-Onset Gender Dysphoria.” Arch Sex Behav. 2020;49(1):61-66. doi:10.1007/s10508-019-1453-2
5. Dowers E, White C, Cook K, Kingsley J. Trans, gender diverse and non-binary adult experiences of social support: A systematic quantitative literature review. Int J Transgender Health. 2020;21(3):242-257. doi:10.1080/26895269.2020.1771805
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