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OBJECTIVE: 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. METHODS: 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. RESULTS: 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. CONCLUSION: 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.
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