Explaining Assigned Sex Ratio Shifts in Trans Children
And Why Trans Male/Masculine Youth Are Relentlessly Depicted as “Girls”
In a companion essay, All the Evidence Against Transgender Social Contagion, I make the case that the apparent increase in the number of children identifying as trans is not due to transness suddenly becoming “contagious,” but rather stems from a reduction in anti-trans stigma and the accompanying trans awareness and acceptance associated with that.
But there is one argument that proponents of “transgender social contagion” or “ROGD” often make that I did not address in that piece, as I felt that it needed some extra unpacking. Specifically, proponents will cite recent shifts in the ratio of trans male/masculine youth (who were assigned female at birth; AFAB) relative to trans female/feminine youth (who were assigned male at birth; AMAB): While the latter were historically more common, nowadays the former seemingly is. This shift is then portrayed as an anomaly that requires further explanation, for which “transgender social contagion” is the proposed culprit.
But the thing is, such shifts can just as easily be explained via the reduction in stigma hypothesis — I will be making that case here. But before I do, it’s crucial to ask: Are these shifts even real? And if so, why would such a shift even matter?
The Relevant Statistics
If you encounter anti-trans campaigners online, they will often bring up variations of the “4,400%” statistic. I could cite numerous examples, but the one I will share here is from J.K. Rowling’s 2020 essay, as it encapsulates several features common to these claims:
Most people probably aren’t aware — I certainly wasn’t, until I started researching this issue properly — that ten years ago, the majority of people wanting to transition to the opposite sex were male. That ratio has now reversed. The UK has experienced a 4400% increase in girls being referred for transitioning treatment. Autistic girls are hugely overrepresented in their numbers.
I initially searched for this statistic on Google Scholar, but found no research articles, which suggests that it doesn’t come from a peer-reviewed study. The most likely source (as several people pointed out to me) is this article in The Telegraph (a UK newspaper) quoting a British politician. The article also mentions that: “Referrals for boys have risen from 57 to 713 in the same period.” Expressed in percentages, that would be a 1,250% increase in trans female/feminine youth, yet anti-trans campaigners never seem to quote this later statistic.
The fact that the trans male/masculine figure is expressed as a percentage (4,400!) rather than in a more comprehensible manner (44 times or fold), coupled with the lack of any similar figure (1,250% or 12.5 times) being applied to trans female/feminine youth, suggests that the article was intentionally worded to exaggerate and raise alarms about the fate of “girls.” (I will come back to this shortly.)
Two weeks ago, in his rebuttal to an open letter expressing concerns about The New York Times’ recent coverage of trans issues (including gender affirmative care), Jonathan Chait raised fears similar to those of Rowling, albeit with better sourced statistics:
“Adolescents assigned female at birth initiate transgender care 2.5 to 7.1 times more frequently than those assigned male at birth,” according to WPATH. This is taking place in the context of a mental health crisis that is disproportionately affecting girls and LGBTQ+ teens.
The quote is from a recent Reuters article, but the cited statistics and language seem to be from WPATH’s recent Standards of Care for the Health of Transgender and Gender Diverse People, Version 8 (SOC8), which you can download via that link. It appears on page S43 and seems to be cherry-picked for dramatic effect. For better context, here is the full paragraph:
Until recently, there was limited information regarding the prevalence of gender diversity among adolescents. Studies from high school samples indicate much higher rates than earlier thought, with reports of up to 1.2% of participants identifying as transgender (Clark et al., 2014) and up to 2.7% or more (e.g., 7–9%) experiencing some level of self-reported gender diversity (Eisenberg et al., 2017; Kidd et al., 2021; Wang et al., 2020). These studies suggest gender diversity in youth should no longer be viewed as rare. Additionally, a pattern of uneven ratios by assigned sex has been reported in gender clinics, with adolescents assigned female at birth (AFAB) initiating care 2.5–7.1 times more frequently as compared to adolescents who are assigned male at birth (AMAB) (Aitken et al., 2015; Arnoldussen et al., 2019; Bauer et al., 2021; de Graaf, Carmichael et al., 2018; Kaltiala et al., 2015; Kaltiala, Bergman et al., 2020).
That paints a rather different picture, one in which trans adolescents are not that rare, and where those who “initiate care” represent a mere subset of the actual trans adolescent population. This is further supported by the many studies reviewed in the “Population Estimates” section of the SOC8 (pages S23–S26). On page S23, WPATH explicitly states:
In clinic-based studies, the data on TGD [transgender and gender diverse] people are typically limited to individuals who received transgender-related diagnoses or counseling or those who requested or underwent gender-affirming therapy, whereas survey-based research typically relies on a broader, more inclusive definition based on self-reported gender identities.
Thus, when researchers cite increases or shifts in trans youth “initiating care” or in “clinic referrals,” those statistics do not describe changes in the actual number of trans people per se, but rather changes in the much smaller subset of trans youth who are currently accessing care. In support of this interpretation (and in contradiction to “4,400%”-style alarmist claims), studies relying on survey data reviewed in that SOC8 section show closer to a 1:1 ratio, with one outlier (a survey of gender-nonconforming high school students; Lowry et al., 2018) displaying three-times more AMAB youth than their AFAB counterparts.
More recently, Turban et al. (2022) examined survey data of almost 200,000 U.S. adolescents and found the ratio to be slightly in favor of trans female/feminine individuals (e.g., an AMAB:AFAB ratio of 1.2 to 1 in 2019).
It is admittedly difficult to compare different surveys with one another, as they will inevitably vary in their demographics, the questions they ask, and so forth. And of course, one can quibble with the specific methodologies of any given study (indeed, this is a strategy for some naysayers!). But the overall trend seems clear: While there may be an assigned sex ratio shift in trans youth “clinic referrals” and “initiating care,” there is no substantive evidence that there’s been a recent “explosion” in the numbers of trans male/masculine people relative to trans female/feminine ones. And that’s not just me saying that — here’s WPATH interpretation of all these population estimates (from page S26):
The trend towards a greater proportion of TGD people in younger age groups and the age-related differences in the AMAB to AFAB ratio likely represent the “cohort effect,” which reflects sociopolitical advances, changes in referral patterns, increased access to health care and to medical information, less pronounced cultural stigma, and other changes that have a differential impact across generations (Ashley 2019d; Pang et al., 2020; Zhang et al., 2020).
In other words, the data support what I’m calling the “reduction in stigma” hypothesis rather than the “social contagion” hypothesis. One of the papers WPATH cites in that passage (Ashley, 2019) adds this:
Given the discrepancies in size between GIC [gender identity clinic] populations and gender-diverse populations, the impact of sociocultural factors on referral patterns is the most promising explanation. Future researchers should resist the impulse to assume that shifts in assigned sex ratios reflect a change of ratio in the gender-diverse population. No evidence currently supports the thesis that the ratio of AFAB and AMAB youth has changed in the overall trans youth population.
Why the Emphasis on “Girls” and Mental Health?
Let’s pretend for a moment that “transgender social contagion” was a real phenomenon. If it was, why should it predominantly impact trans male/masculine youth? Proponents of the theory — including the trans-skeptical parent who invented it and Lisa Littman (who re-branded it as “ROGD”) — assert that it spreads via social media (with Tumblr, Reddit, and YouTube explicitly mentioned) and friend groups. I’m pretty sure that trans female/feminine youth have access to all those things too! So shouldn’t they be similarly affected?
Another common assertion is that “transgender social contagion” disproportionately impacts individuals who are autistic and/or have other mental health issues (as seen in the Rowling and Chait quotes above, and alluded to throughout Littman’s original uncorrected ROGD paper). Of course, some trans people (both AMAB and AFAB) do experience such things, but they are not considered to be contraindications for gender-affirming care. Here’s an excerpt from the WPATH SOC8 chapter on Mental Health (from pp. S171–S172; I have deleted all the citations to make this passage easier to read):
Some studies have shown a higher prevalence of depression, anxiety, and suicidality among TGD people than in the general population, particularly in those requiring medically necessary gender-affirming medical treatment. However, transgender identity is not a mental illness, and these elevated rates have been linked to complex trauma, societal stigma, violence, and discrimination. In addition, psychiatric symptoms lessen with appropriate gender-affirming medical and surgical care and with interventions that lessen discrimination and minority stress . . . Addressing mental illness and substance use disorders is important but should not be a barrier to transition-related care. Rather, these interventions to address mental health and substance use disorders can facilitate successful outcomes from transition-related care, which can improve quality of life.
Similarly, some trans people also experience autism/neurodivergence, and knowledgeable trans health professionals strive to simultaneously support such individuals on both counts (see e.g., Strang et al., 2020). The WPATH SOC8 explicitly states (on page S37): “There is no evidence to suggest a benefit of withholding GAMSTs [gender-affirming medical and/or surgical treatments] from TGD people who have gender incongruence simply on the basis that they have a mental health or neurodevelopmental condition.
As many people prior to me have pointed out, “transgender social contagion” proponents’ repeated emphasis on “girls” and mental health seems designed to appeal to sexist and ableist presumptions that such individuals are not fully competent to truly understand themselves and to make decisions about their own bodies and lives.
But I think that there’s also something more going on here. As I mentioned in my companion essay, members of dominant/majority groups (in this case, cisgender people) tend to view stigmatized minorities as “contaminated” and capable of “corrupting” supposedly “pure” ingroup members. This unconscious “contamination” mindset drives fears that marginalized groups may be contagious (e.g., “turning people gay,” “transgender social contagion”) as well as sexually corrupting (e.g., “sexual deceivers,” “restroom predators,” “groomers”). [I discuss this mindset in more depth in this essay and in Chapters 7 & 8 of my book Sexed Up.]
The greater the disparity one can create between the supposedly “contaminated, corrupting, dangerous outgroup” and the “pure, innocent, vulnerable ingroup,” the more atrocious the imagined threat will seem. This is why moral panics (including this latest anti-trans rendition) are almost always centered on “protecting women and children,” especially those who are white, middle-class, and otherwise unmarked (read: “uncontaminated” and therefore “pure”).
Anti-trans campaigners have increasingly played into this mindset by portraying trans activists as “adult males” who supposedly “prey” (whether ideologically or sexually) on innocent and vulnerable “young girls.” Depicting said “girls” as mentally incompetent (due to supposed feminine fragility, neurodivergence, mental health issues, etc.) serves to further amplify their imagined innocence and vulnerability.
Perhaps the best illustration of this mindset can be found in Abigail Shrier’s recent book Irreversible Damage: The Transgender Craze Seducing Our Daughters. The book focuses almost exclusively on how “social contagion” is ravaging “our girls,” with a brief diversion (via interviews with Ray Blanchard and J. Michael Bailey) to depict trans adults as “sexually deviant men.” While the book doesn’t explicitly discuss “grooming,” it’s suggested in the subtitle (“seducing our daughters”) along with the phrase “transgender craze” (implying that these kids’ trans identities are caused or enabled by mental illness). Oh, did I mention that the cover image is a cartoon of a young girl with a hole cut out where her reproductive parts would be (read: she has been “defiled”).
This mindset also informs trans-skeptical depictions of detransition. While people detransition/retransition for numerous reasons, and fall along varied trajectories, anti-trans campaigners and cisgender media producers seem most interested in telling one particular story: the “young girl” who transitioned but now regrets it, often with an emphasis on how “gender ideology” and gender-affirming care “ruined” her life and body. Media outlets find this narrative so compelling that they typically play down or fail to mention that some of their subjects transitioned as adults, detransitioned for ideological reasons, and/or are closely associated with anti-trans groups. What gets lost in the fray are the experiences of AMAB detransitioners, those who detransition due to a lack of family or community support, and those who don’t regret the gender-affirming care they’ve received in the past (as these don’t fit the “pure and innocent ingroup member contaminated and corrupted by insidious outsiders” narrative).
To be clear, I don’t think that every person who promotes this narrative, or with whom this narrative resonates, is purposely engaging in sexism, ableism, or is intentionally promoting transphobia. Stereotypes and mindsets tend to work at the unconscious level, which is why they are so compelling and so difficult to refute. But I do hope that this section helps readers recognize the hallmarks of this “contamination” mindset, how it drives fears of “social contagion” and “grooming,” and the central role it plays in moral panics more generally.
Traditional Sexism and Disparities in Accessing Gender Affirmative Care
Countless studies (many of which are reviewed in the WPATH SOC8) have repeatedly shown that gender-affirming care has a very positive impact on trans youth. Given this, rather than fearmongering about trans youth “initiating care,” perhaps we should be raising concerns about why only a small subset of trans youth are able to access said care in the first place. And instead of referring to this matter in terms of a “sex ratio shift” (which makes it sound like a new development), we should reframe it as “gender disparities in access to gender-affirming care” (which have always existed).
An implicit assumption of the “sex ratio shift”/“transgender social contagion” narrative is that the ratios of the past (back when trans female/feminine people represented the majority of gender clinic referrals) must be some kind of “natural baseline” from which we are now deviating. But those numbers have always been skewed, as I detailed in my 2007 book Whipping Girl. What follows is a super-brief synopsis of the arguments I made there.
All trans people face transphobia. But traditional sexism (the presumption that femaleness and femininity are inferior to or less legitimate than maleness and masculinity) shapes how trans people of different trajectories are perceived and interpreted. Specifically, trans female/feminine people tend to face disproportionate attention, scrutinization, and demonization because of the direction of our gender transgressions and transitions (toward the female and/or feminine). In Whipping Girl, I called this phenomenon transmisogyny (that link brings you to an explainer essay, or you can read this encyclopedia entry).
Throughout Whipping Girl, I discuss how transmisogyny has shaped media depictions, which have historically dwelled on trans female/feminine people (because it’s easier to sexualize and sensationalize us, and to caricature us as “fake”), while largely ignoring trans male/masculine people (resulting in invisibility). Similar dynamics occurred in twentieth-century trans-related research and medical gatekeeping, which focused primarily on trans female/feminine people, as we were deemed more “psychopathological” in their eyes. Several decades of studies have shown that people tend to be more disturbed by “feminine boys” than “masculine girls” (Martin, 1990; Sandnabba & Ahlberg, 1999; Kane, 2006; Sullivan et al., 2018), so it’s no surprise that parents were more likely to bring the former children in for psychotherapy than the latter. (This was during a time when conversion therapy, rather than gender-affirming care, was the norm.)
As someone who grew up back then (I’m generation X), transgender trajectories were greatly shaped by these forces. Like a lot of trans female/feminine people my age, I was aware of the existence of trans women from media depictions, but because they were so pervasively ridiculed and stigmatized, I spent my teen and young adult years attempting to avoid that fate at all costs. Trans men my age often told a different story: They were aware that trans women existed, but had never heard of trans men, so they didn’t know that transitioning was even a possibility for them until much later in life. This invisibility helps to explain gender clinic statistics of the time showing that trans women were supposedly three times “more prevalent” than trans men.
Fast forward to the twenty-first century. As anti-trans stigma has gradually decreased, and trans visibility and awareness have reciprocally increased, more and more trans people (whether children, adolescents, or adults) are able to put what they are feeling into words, and find information and resources regarding what they need. This is why the number of people who identify as trans (whether in surveys or via accessing gender-affirming care) has been rising. But traditional sexism is still quite pervasive, as seen in the concerted effort to infantilize trans male/masculine teens and young adults as “girls who are too vulnerable and irrational to make sound decisions for themselves.” And traditional sexism also drives transmisogynistic stereotypes of trans female/feminine people as extremely artificial (“parodies of women”) and sexually motivated (“promiscuous,” “fetishists,” “predators,” “groomers”). I’ve talked to many trans women who have told me that these stereotypes prevented them from coming out until their mid-twenties or thirties or later — this could partially account for why fewer trans female/feminine adolescents are accessing gender-affirming care relative to their trans male/masculine counterparts.
In support of this, consider the study “Evidence for a Change in the Sex Ratio of Children Referred for Gender Dysphoria: Data From the Gender Identity Development Service in London (2000–2017)” (de Graaf et al., 2018). Like other clinics, they observed an overall shift toward trans male/masculine referrals, but they also noticed a significant age bifurcation, one that favored trans female/feminine children in the 3–9 years old range, but favored trans male/masculine children in the 10–12 years old range. In their Discussion, here’s how they explained the former:
The sex difference in the age at referral probably reflects, among other things, greater parental worry about marked gender-variant behavior in sons than in daughters (eg, concerns about peer ostracism).
For the latter, they suggested:
At present, the reasons for this shift in the sex ratio among adolescents are not clear, but may include less stigma for birth-assigned girls who are behaviorally masculine compared to birth-assigned boys who are behaviorally feminine, which makes it easier to “come out” as transgender and to seek out mental health care and biomedical treatment.
Unlike “transgender social contagion,” the reduction in stigma model that I’ve presented here and in the companion essay is not one-size-fits-all. It’s dynamic and can accommodate numerous forms of stigma (traditional sexism, transphobia, ableism, racism, classism, etc.) which may intersect and play out differently for any particular individual, or within any given culture or time period. Rather than “turning people transgender,” gradual (or sudden) shifts in stigma may influence when and how individuals learn about trans people, how they react to that knowledge (by coming out, or remaining closeted), and what possibilities are available to them (socially transitioning at a young age, or waiting well into adulthood; having a relatively normal life, or being forced to the margins of society).
I doubt that anything I’ve said here will change the minds of die-hard anti-trans campaigners who insist on disaffirming trans youth at all costs. But I hope that this essay encourages everyone else to relinquish overly simplistic (and often outdated) trans narratives, and to recognize that shifts in transgender demographics, trajectories, and identities are not “signs” or “symptoms” that something has gone wrong. Rather, like our culture more generally, we are constantly evolving.
This article and its companion essay, “All the Evidence Against Transgender Social Contagion,” were made possible by my Patreon supporters — if you appreciate them, please consider supporting me there!
