Social Contagion and the Changing Demographics of Sex-Discordant Gender Identity

BY PAUL W. HRUZ, M.D., PH.D.

The past decade has witnessed a dramatic, worldwide increase in both the number of specialized “gender clinics” and the number of persons presenting to them. Sex-discordant gender identity, a condition that in 2012 affected less than one in every 20,000 to 30,000 individuals, is now reported in the U.S. to affect nearly one in every 200 adults and one in every 70 teenagers.

While historical data from the Netherlands and other sources previously revealed that the majority of patients seeking gender-affirming medical interventions were biological males desiring to appear as women, there has been a dramatic reversal of this trend. Now females desiring to appear as men represent the majority of new patients. Data from multiple studies performed in the U.S. and worldwide consistently show this trend reversal in the incidence of sex-discordant gender identity.

Notably, the majority of affected adolescent females are presenting without any childhood evidence of gender dysphoria. Despite their strong desire for interruption of normal puberty with the administration of GnRH analogs, the administration of sex-incongruent steroid hormones, and access to surgical modification of their sexual phenotype, there remains little if any high-quality scientific evidence for the safety and long-term efficacy of these interventions.

In contrast to the aggressive promotion of the affirmative approach to gender dysphoria in the United States, a shift toward a more cautious approach is underway in several European countries. That movement is based on systematic reviews that have exposed known and potential risks and the lack of proven long-term benefit of this interventional model in preventing psychological morbidity, including the risk of suicide.

There are several hypotheses for the increase in the incidence of sex-discordant gender identity among females, including increased access to medical centers offering interventions to alter external sexual appearance and changes in societal acceptance of gender non-conforming people. Yet there are no rigorous scientific data to establish the validity of these explanations. An alternate and arguably stronger hypothesis is that this new phenomenon is the result of social contagion.

Dr. Lisa Littman first proposed this intriguing hypothesis in 2018 with a seminal paper published in the highly respected open access journal Plos One. Immediately following the publication of her study, a media firestorm erupted, leading to the nearly unprecedented demand for re-review of the paper. This resulted in some stylistic revision but no fundamental change to data interpretation. Importantly, Dr. Littman acknowledged that her study was not definitive, but merely provided a strong rationale for further hypothesis testing.

In stark contrast to the media coverage of Dr. Littman’s paper, a paper published this year by Jack Turban and colleagues in Pediatrics, the flagship journal of the American Academy of Pediatrics, received widespread media acclaim. This occurred despite the presence of several methodological limitations, overt biases, and erroneous conclusions. The authors claimed that the failure to observe a change in the sex ratio of transgender youth in their study disproved the existence of rapid onset gender dysphoria. Yet, their data is from a subset of the U.S. population collected over a two-year timeframe by cross-sectional survey on self-reported sex and gender identification. It does not include a report of the number of biological females diagnosed with gender dysphoria.

In seeking an answer to the question of why there has been such a significant escalation of adolescent females who are presenting with sex-discordant gender identity, it must be acknowledged that the precise cause of gender dysphoria remains unknown. From the available evidence, it is likely that this condition is multifactorial with genetic, psychological and environmental contributors.

However, in light of established general understanding of adolescent identity development, a highly plausible hypothesis is that social factors are a major contributing influence.

Consideration of the theories of psychologists Erik Erikson, who described the “identity versus confusion” developmental task of teenagers, and James Marcia, who expanded this concept to include the “essential task of identity exploration and commitment,” strengthen this hypothesis. The scientifically established link between social exposures and other conditions such as eating disorders, substance abuse and suicide further provide a strong foundation for positing that social contagion contributes to gender dysphoria in youth.

With the pervasiveness of social media use among adolescents and the known influence of this exposure on body satisfaction, I propose that media and peer exposure to gender ideology of vulnerable adolescents undergoing a critical stage of identity development is a “perfect storm” for the proliferation of sex-discordant gender identification. Beyond the theoretical, existing data on the number of gender dysphoric youth who also suffer from body dysmorphia, including anorexia and other eating disorders and for which there is an established association with social media use, is consistent with the hypothesis of a causal link between social media use and the emergence of sex-discordant gender identity.

To address the growing epidemic of adolescents experiencing sex-discordant gender identity, I provide several common-sense suggestions for parents and others who have significant roles in raising children to maturity. Specifically, parents can assist identity development in their children by setting reasonable limits to social media access, regularly monitoring social media use, establishing clear boundaries of acceptable and non-acceptable behavior, encouragement of face-to-face contact with peers, and the setting of good parental example of media use.

In addition to better understanding and explaining the cause or causes of gender dysphoria, there remains an urgent need to design and conduct high-quality controlled research studies to address the remaining deficiencies in scientific evidence related to the current care of adolescents who experience significant suffering from sex-discordant gender identity.

Dr. Paul Hruz is a pediatric endocrinology specialist in Saint Louis, Missouri and co-author of the recently published book Sexual Identity: The Harmony of Philosophy, Science, and Revelation. He presented on this topic at the CMA’s 91^st Annual Educational Conference in Denver, Colorado on Sept. 8. His presentation is available for purchase here.