Sex Assigned at Birth Ratio Among Transgender and Gender Diverse Adolescents in the United States

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.

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.

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 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.

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.

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.

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.

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).

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 

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.

We thank the YRBS adolescent participants and local education agencies for their continuous engagement in population health research.

Abbreviations
 
• AFAB

  assigned female sex at birth

 
• AMAB

  assigned male sex at birth

 
• ROGD

  rapid-onset gender dysphoria

 
• TGD

  transgender and gender diverse

 
• YRBS

  Youth Risk Behavior Survey