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.

 

 

 

 

 

 

 

As authors of a manuscript under review that utilized data from the YRBSS to investigate the relationship between suicidality and experiences of bullying among sexual and gender minority youth, we feel compelled to document our concerns about the recent publication “Sex Assigned at Birth Ratio Among Transgender and Gender Diverse Adolescents in the United States” by Turban et al.
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.

As a psychotherapist who has been working with gender questioning young people and their families since 2016, I am unconvinced by Turban and colleagues’ recent Pediatrics article “Sex Assigned Birth Ratio among Transgender and Gender Diverse Adolescents in the United States.” Other commentators have addressed the significant methodological issues with the paper. Turban’s assertion that his findings disprove the social influence hypothesis that has been offered to explain the rise in trans identifying teens and young people contradicts my clinical experience.
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/

In “Sex Assigned at Birth Ratio among Transgender and Gender Diverse Adolescents in the United States”, Turban et al. claim that their study contradicts 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”.1 However, the data they report do not support these claims. In fact, the study design and dataset used are not equipped to address these questions at all.

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

Authors: Elle Lett,PhD, MA, MBiostat; 1,2,3 Avery Everhart, PhD;1,4,5 Carl Streed Jr, MD, MPH;6,7 Arjee Restar, PhD, MPH1,8,9
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 care^2,3 – 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 school^9–11 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
6. 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. Morb Mortal Wkly Rep. 2019;68(3):67-71. doi:10.15585/mmwr.mm6803a3
7. Centers for Disease Control and Prevention. Participation Maps & History | YRBSS | Adolescent and School Health | CDC. Published August 18, 2021. Accessed August 4, 2022. https://www.cdc.gov/healthyyouth/data/yrbs/participation.htm
8. Lett E, Everhart A. Considerations for Transgender Population Health Research Based on US National Surveys. Ann Epidemiol. Published online October 28, 2021. doi:10.1016/j.annepidem.2021.10.009
9. Movement Advancement Project | Safe Schools Laws. Accessed August 4, 2022. https://www.lgbtmap.org/equality-maps/safe_school_laws
10. Kosciw JG, Clark CM, Truong NL, Zongrone AD. The 2019 National School Climate Survey: The Experiences of Lesbian, Gay, Bisexual, Transgender, and Queer Youth in Our Nation’s Schools. A Report from GLSEN. ERIC; 2020.
11. State Policy Scorecards | GLSEN. Accessed August 4, 2022. https://maps.glsen.org/state-policy-scorecards/
12. Baker KE, Streed CG, Durso LE. Ensuring That LGBTQI+ People Count — Collecting Data on Sexual Orientation, Gender Identity, and Intersex Status. N Engl J Med. 2021;384(13):1184-1186. doi:10.1056/NEJMp2032447