“Social contagion” is not driving an increasing number of adolescents to come out as transgender, according to a new study published Wednesday in the journal Pediatrics. 

The study also found that the proportion of adolescents who were assigned female at birth and have come out as transgender also has not increased, which contradicts claims that adolescents whose birth sex is female are more susceptible to this so-called external influence. 

“The hypothesis that transgender and gender diverse youth assigned female at birth identify as transgender due to social contagion does not hold up to scrutiny and should not be used to argue against the provision of gender-affirming medical care for adolescents,” study senior author Dr. Alex S. Keuroghlian, director of the National LGBTQIA+ Health Education Center at the Fenway Institute and the Massachusetts General Hospital Psychiatry Gender Identity Program, said in a statement.

The “social contagion” theory can be traced back to a 2018 paperpublished in the journal PLOS One. Dr. Lisa Littman, who at the time was a professor of behavioral and social sciences at Brown University, coined the term “rapid onset gender dysphoria,” which she described as adolescents experiencing a conflict between their birth sex and gender identity “suddenly during or after puberty.” These adolescents, she wrote, “would not have met the criteria for gender dysphoria in childhood” and are experiencing dysphoria due to social influence.  

Littman also hypothesized that adolescents assigned female at birth are more likely to be affected by social contagion and, as a result, are overrepresented in groups of adolescents experiencing gender dysphoria when compared to those who were assigned male at birth.

After intense debate and criticism, PLOS One conducted a post-publication reassessment of the article, and issued a correction that included changing the headline to clarify that Littman did not survey transgender or gender-diverse youth themselves, but actually surveyed their parents. The correction also noted that, “Rapid-onset gender dysphoria (ROGD) is not a formal mental health diagnosis at this time.”

To test the social contagion theory, researchers used data from the 2017 and 2019 biennial Youth Risk Behavior Survey conducted by the Centers for Disease Control and Prevention, which collected gender identity data across 16 states from ages 12 to 18. In 2017, 2.4%, or 2,161 of the 91,937 adolescents surveyed, identified as trans or gender diverse. In 2019, that percentage dropped slightly to 1.6%, or 1,640 of 105,437 adolescents surveyed.

Researchers concluded that the decrease in the overall percentage of adolescents identifying as trans or gender diverse “is incongruent with the (rapid-onset gender dysphoria hypothesis) that posits social contagion.” 

The study also found that the number of transgender adolescents who were assigned male at birth outnumbered those assigned female at birth in both 2017 and 2019, providing additional evidence against a “notion of social contagion with unique susceptibility” among those assigned female at birth.  

The social contagion hypothesis, by assuming that youth are coming out, for example, because their friends are, asserts that there’s some social desirability to being trans. Some supporters of the theory, according to the study, also believe that more youth identify as trans or gender diverse because those identities are less stigmatized than cisgender sexual minority identities, or those who identify with their birth sex and are lesbian, bisexual, gay or queer, among other sexual identities.  

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To evaluate these claims, researchers examined rates of bullying among adolescents who identified as trans and gender diverse, and those who did not.

They found that, consistent with other surveys, trans and gender-diverse youth were significantly more likely to be victims of school bullying (at 38.7% in 2017 and 45.4% in 2019) compared to cisgender lesbian, gay and bisexual youth (at 30.5% in 2017 and 28.7% in 2019) and cisgender, heterosexual youth (at 17.1% in 2017 and 16.6% in 2019).

“The idea that attempts to flee sexual minority stigma drive teenagers to come out as transgender is absurd, especially to those of us who provide treatment to [transgender and gender diverse] youth,” study lead author Dr. Jack Turban, incoming assistant professor of child and adolescent psychiatry at the University of California, San Francisco, said in a statement. “The damaging effects of these unfounded hypotheses in further stigmatizing transgender and gender diverse youth cannot be understated. We hope that clinicians, policymakers, journalists, and anyone else who contributes to health policy will review these findings.” 

They wrote that despite the methodological flaws in Littman’s study, the concept of rapid onset gender dysphoria “has been used in recent legislative debates to argue for and subsequently enact policies that prohibit gender-affirming medical care” for trans and gender diverse adolescents. 

For example, in June, Florida’s Agency for Health Care Administration issued guidance against gender-affirming care for minors — including social transition, which involves changing a child’s name, pronouns, clothing and/or hairstyle. The guidancelinked to reports that cited Littman’s paper.

An increasing number of states have also tried to ban or restrict trans youths’ access to gender-affirming medical care through legislation. The number of bills seeking to restrict gender-affirming health care for transgender youths has grown from one in 2018 to 36 this year, according to an analysis by NBC News. Governors in three states — Alabama, Arkansas and Tennessee — have successfully signed such restrictions into law, though judges have prevented those measures from taking effect in Alabama and Arkansas. 

The study lists several limitations, including that the data were collected through a school-based survey and, as a result, youths who don’t attend school were not represented. It also noted that youths were asked, “What is your sex?” and that response options were limited to female and male. It didn’t ask about respondents’ “sex assigned at birth” and didn’t include an additional question about their “gender identity,” which is an established research method for asking about gender identity. But the researchers credited severalstudies that found trans and gender-diverse youths are aware of the differences between their sex assigned at birth and gender identity.