Understanding the Rise of Transgender Identities

Men, it has been well said, think in herds; it will be seen that they go mad in herds, while they only recover their senses slowly, and one by one.
~Charles Mackay

People’s extraordinary sensitivity to the beliefs and behaviors of others, especially successful and socially visible others, contributes to the spread of useful skills and ideas and is critical to building and maintaining cultural knowledge. The benefits that follow from this sensitivity, however, come with the risk of being swept up in popular delusions. As Mackay noted, “We find that whole communities suddenly fix their minds upon one object, and go mad in its pursuit; that millions of people become simultaneously impressed with one delusion, and run after it, till their attention is caught by some new folly more captivating than the first.”

Susceptibility to popular delusions appears to be a human universal, although some people are more susceptible than others. These delusions can coalesce around just about anything the human mind can imagine, from get-rich-quick schemes to fear of demonic possession to blaming outgroups for moral decay. And though they are sometimes innocuous, they are also potentially dangerous. In Europe from 1500–1700, for example, tens of thousands of women and men were killed for being witches.

Debates and ideas about the number of sexes or genders and associated identities have all the makings of a popular delusion. A Google search for “gender identity” yields more than 800,000,000 entries; the same search under news yields more than 12,500,000 entries. Public discussion is clearly fixated on the topic, despite the indisputable evidence that there are only two sexes in complex organisms and that issues with gender identity have been historically uncommon.

A transgender person is someone whose natal sex (sex assigned at birth) does not match their gender identity (e.g., a natal female who identifies as a man). In some cases, a person’s gender identity may fall into a category other than “man” or “woman,” a state that is often labeled “non-binary.” There are in fact people with gender dysphoria (persistent and intense distress over one’s natal sex) and related concerns; that is not at issue.

Instead, the issue is the startling recent increase in the numbers of individuals who identify as transgender (or some related identity) and the risk of false positives, that is, individuals who for whatever reason believe they are transgender but are not. If the belief stayed in the individual’s mind and immediate social circles, there is no harm done. However, irreversible medical interventions are increasing as well, along with attendant risk of mistaken interventions that are later regretted.

Lisa Littman exposed this five years ago, writing that the current expression of gender dysphoria “is distinctively different than what is described in previous research … because of the distribution of cases occurring in friendship groups with multiple individuals identifying as transgender, the preponderance of adolescent (natal) females, the absence of childhood gender dysphoria, and the perceived suddenness of onset.” In other words, a large group of adolescent girls’ (and some adolescent boys’) understanding of their sexual identity has been influenced by their peer groups. These children do not show typical patterns (e.g., cross-sex play) associated with gender dysphoria and a transgender identity. The pushback against Littman’s argument was immediate and severe and continues to this day in the medical literature and more broadly.

It’s a good time to revisit this issue and to explore and try to explain the recent increase in the number of adolescent girls and young women who have a transgender or related identity. The argument is not that gender dysphoria and transgender identities are unreal, but that the almost obsessive fixation on transgender issues is increasing the risk of false positives (e.g., misattributing emotional distress to gender identity when the underlying cause is something else) among adolescents and young adults. I focus here on girls and women because of the changes in the demographics associated with gender dysphoria and gender identity issues. As Mackay illustrated, men are also prone to social contagion effects, but these occur more often with status-related beliefs, such as get-rich-quick schemes and collective violence. Adolescent girls and young women, in contrast, may be more attracted to inclusion in a socially supportive community, with benefits, such as increased social attention and popularity.

How common are transgender people?

Estimates of the number of people who identify as transgender or non-binary vary widely, depending on criteria for inclusion and the population being studied. Some of these estimates come from the percentage of the population who has sought, or is seeking, some form of medical intervention (e.g., surgery, hormone treatments). Other estimates are based on survey responses to questions about a transgender or ambivalent gender identity (e.g., non-binary).

Prevalence estimates for those who have received or are seeking a medical treatment are based on the number of people served by gender clinics relative to the size of the clinic’s catchment population. These studies indicate a low but increasing prevalence. In past eras, twice or three times as many natal males as females sought such treatment. One meta-analysis (a respected method for combining results across studies) published in 2015 indicated that one in every 14,705 individuals were transwomen (i.e., natal males who identified as women), and one in every 38,461 individuals were transmen (i.e., natal women who identified as men). A more recent study estimated that in 1976 about one in every 17,857 natal males and one in every 52,632 natal females sought hormone therapy as a treatment for gender identity and related concerns. By 1990, one in 11,905 natal males and one in 30,303 natal females sought similar treatments, indicating a modest increase from 1976 to 1990.

The trend has accelerated since then. Based on the National Inpatient Sample (US), Canner and colleagues found that from 2000 to 2014, the proportion of inpatients with gender-related diagnoses more than tripled, as did the proportion of individuals seeking a medical intervention (e.g., genital surgery). Leinung and Joseph found that the number of people seeking hormone therapy in upstate New York increased steadily from 1991 to 2016 and that the change was especially pronounced for natal females: “The percentage of individuals seeking transition to male gender was frequently 0% in the years up to 2002, but increased thereafter with the average increase in percentage seeking transition to male gender rising by 21% per decade.” The ratio of men to women seeking hormone therapy is now close to 1:1. Similarly, Aitken and colleagues found that the number of adolescents seeking treatment for gender dysphoria increased substantively after about 2006 and that the sex ratio flipped from more natal males (1.5 to two times more) before 2005 to more natal females after this (1.7 to 1.8 times more).

Studies based on the number of people seeking surgical or hormonal treatment underestimate the proportion of the population that identifies as transgender. A review of large national (US) surveys revealed that one in 256 people identified as transgender in 2016, which is about twice the number in 2007. The change across time was especially large for college students. In 2009, one in 665 students identified as transgender, as compared to one in 56 in 2016, a nearly 12-fold increase in seven years! A more recent review indicated that from 2017–2020, about one in 200 adults in the US identified as transgender, as did one in 71 adolescents. The figure below shows that among those who identify as transgender, the percentage of adolescents and young adults is larger than would be expected based on their share of the overall US population. As with individuals seeking medical treatments, the ratio of transwomen (natal men) and transmen (natal women) is approaching 1:1 (specifically, 1.07:1).

The proportion of adolescents and young adults identifying as transgender varies considerably across US states. In the state of New York, one in 33 adolescents identify as transgender as compared to one in 179 in Wyoming. Arkansas boasts the largest percentage of young adults identifying as transgender (one in 28) and, about 650 miles to the north, Iowa the lowest (one in 222). There are also reports of more localized spikes in the number of adolescents identifying as transgender or non-binary. One recent study found that nearly one in 10 high school students in a north-eastern school district identified as transgender or non-binary.

These wide variations and localized spikes are consistent with social influences on the likelihood of identifying as transgender (or a related identity). Some of these changes may be related to the laudable goal of removing the stigma associated with a transgender identity. However, the rush to destigmatize, support, and affirm those with gender dysphoria and gender identity issues, combined with social media, has created incentives to mimic these issues to gain support and affirmation. These motivations almost certainly increase false positives and promote harmful, unnecessary medical interventions.

Why are rates increasing among adolescent girls and young women?

Both men and women can be swept into widely held social beliefs, but adolescent girls and young women might be more vulnerable to certain types of beliefs. Eagly noted that women have, on average, more communal traits as “manifested by selflessness, concern with others, and a desire to be at one with others,” whereas men have, on average, more agentic traits as manifested by “self-assertion, self-expansion, and the urge to master.” These differences are reflected in how the sexes form and maintain social relationships. Boys’ and men’s groups are larger, more integrated, more open to new recruits, and often focused on a specific outcome, such as competing against another group of males. Larger groups provide a competitive advantage, but at the cost of less social and emotional support for individual relationships.

In contrast, girls’ and women’s communal motivations include the cultivation of a network of relationships that provides them with social and emotional support and a sense of safety. These relationships are more intimate, time-intensive, and exclusive than those of boys and men. Girls’ and women’s social behavior (e.g., language expressiveness, social smiles) fosters the initiation of friendships and helps to maintain them. Girls are more engaged with, and know more about, their best friend than boys. Girls also are more sensitive to the social-emotional cues of their partner and work harder to minimize perceived inequalities in the relationship.

Girls’ and women’s social styles provide clear benefits for relationships, but also costs: The intensity and sensitivity to perceived inequalities in their relationships make adolescent girls’ and young women’s friendships more fragile than those of boys and men and result in a heightened fear of social rejection and exclusion from the group. The associated goal of making other girls and women feel welcome and supported to allay fears of exclusion might also increase the risk of going along with questionable ideas to avoid conflict and maintain social cohesion. We see hints of this in social-psychological experiments where young women are more likely than men to agree with the clearly false statements of a group of strangers.

The social and emotional pressure to cling to ideas that help maintain the groups’ cohesion and supportive social dynamics are likely to be intense for some girls, especially those who perceive they are not well supported in other areas of their life. The motivation to be part of a supportive social network with a shared sense of purpose and unifying beliefs might contribute to the overrepresentation of women in some cults and sensitivity to social contagion.

These issues are amplified by social media and the associated algorithms that tailor searches to individual interests. Unsurprisingly, there’s now evidence of media-driven social contagion, such as through YouTube videos. Müller-Vahl and colleagues documented an uptick in referrals to specialty clinics to evaluate Tourette-like symptoms that mimicked the symptoms of a popular YouTuber with mild Tourette’s syndrome. Related videos soon appeared, with just as many boys as girls mimicking a popular male YouTuber with symptoms, but with nine girls for every boy mimicking a popular female YouTuber. The differing ratios suggest that girls are especially influenced by their same-sex peers. These types of contagions can occur in both sexes, but are about 2.5 times more likely to spread in girls’ than boys’ groups, especially in children and young adolescents.

Transitions and detransitions

If the current social fixation on transgender issues has increased inaccurate self-appraisals of one’s gender identify, rates of detransitioning (e.g., stopping of hormone treatments) and regrets should be increasing as well. Social or medical detransitioning and regrets about the original transition have been low, historically. Reviewing findings collected in large part before the recent increases in transgender identity, Bustos and colleagues’ meta-analysis indicated that regret after transitioning was uncommon (about one percent). In a relatively large Swedish study, Dhejne and colleagues also found that regret among individuals who had medically transitioned between 1960 and 2010 was low (2.2 percent). To reduce the risk of false positives, the individuals who transitioned had documented gender dysphoria since childhood and underwent a multi-step year-long series of evaluations before surgery. Unlike the recent flip from more natal males to just as many or more natal females with gender dysphoria or transgender identity, there were more natal males than females in this study (1.42:1 to 1.93:1). Surgeries increased over time, but were still rare in 2010, with one in 15,047 natal women receiving treatment for female-to-male transitions and one in 8,636 natal males for male-to-female transitions.

So, in Sweden between 1960 and 2010, about one in 10,000 people sought, were evaluated for, and successfully completed transition, and relatively few had regrets and requests to detransition. However, Roberts and colleagues’ more recent study (covering 2009 to 2018) suggests the latter might no longer be the case. Here, the four-year continuation rate for hormone treatments was 81 percent for transwomen (natal males), as compared to 64 percent for transmen (natal females). Nearly two out of three of their patients started treatment in the last 22 months of the study and, as with many other recent studies, there were more natal females than males (2:1).

Based on this study and other recent ones, Irwig concluded that it “is quite possible that low reported rates of detransition and regret in previous populations will no longer apply to current populations.” As described, these current populations include an overrepresentation of adolescents and young adults and especially adolescent girls and young women.

My suggestion is that the social dynamics of girls’ and women’s friendship groups, including a desire to fit in and avoid conflict, have contributed to the change in the transgender population, consistent with Littman’s original observations. In her study, the majority (83 percent) of those with a rapid change in gender identify were adolescent girls, many of whom adopted it when it spread to their social network. However, the Littman study is based on parental reports and not a direct assessment of these adolescents or later regrets.

The Roberts study, a direct assessment with a four-year follow-up, not only found more natal females than males seeking treatment to transition, but also that natal females were 2.4 times more likely to detransition (i.e., stop hormone treatment) than their male peers. Roberts and colleagues did not explore the reasons for the decisions to transition and detransition, but Littman did in a follow-up study. The study focused on potential social contagion effects for individuals who have detransitioned. Most (69 percent) of these individuals were natal females. Regardless of natal sex, most believed that transitioning would alleviate gender dysphoria or other psychological issues. “Participants identified sources that encouraged them to believe transitioning would help them. Social media and online communities were the most frequently reported, including YouTube transition videos (48.0%), blogs (46.0%), Tumblr (45.0%), and online communities (43.0%).” Many (22 percent to 36 percent) were in friendship groups or had friends who were focused on transgender. About 20 percent reported social popularity increases after transitioning. Social pressure, however, worked both ways, as some of the individuals who detransitioned reported being pressured (e.g., by parents) to do so. The study is important but can be challenged because it was not a random sample of people who had transitioned.

Nonetheless, these findings need to be considered in the broader context of recent spikes in the numbers of adolescents and young adults identifying as transgender (or a related identity) and the widespread availability of transgender information on social media, the Internet, and even from professional organizations. Some of these organizations are arguing for tearing down the old guard rails that likely reduced false positives and contributed to the historically low regret rates among those who transitioned. Tearing down the guard rails makes it easier to take a gender affirming approach, but will also increase the risk of regrets and unnecessary medical interventions.

The combination of the current social fixation on transgender issues, the availability of easily accessible information that supports the adoption of a transgender identity (e.g., to explain discomfort with normal physical changes during puberty), and the broad approach to provide social support and affirmation unconditionally make for a perfect storm. This storm is likely to seize individuals who are struggling with social and emotional issues and looking for a social support network that will help them understand and cope with these issues. Many of the social support networks that have emerged for people with transgender issues have features that overlap those of adolescent girls’ and young women’s naturally occurring support networks. This overlap, in turn, makes girls more susceptible to transgender messaging.

Moving forward

The number of individuals seeking treatments for gender identity and related issues has increased dramatically in recent years, especially among adolescent girls and young women. The historical pattern of far more natal males than females identifying as transgender or indicating gender dysphoria has reversed, with just as many or more natal females than males now doing so. Doubtless there are many reasons for these changes, including greater acceptance of gender dysphoria and transgender and related identities and an increased availability of associated treatments. These are positive developments, but at the same time, greater tolerance is unlikely to explain every case, or even most of them, especially the rapid increase in the number of adolescent girls identifying as transgender or non-binary.

In fact, zeal for providing unflinching support and affirmation of those with a transgender or related identity has created an environment that can be very attractive to young people, especially those who are troubled or isolated. The attraction may be especially great for adolescents and young adults, in particular girls and women who are seeking this type of support, affirmation, and a ready-made explanation for social and psychological struggles that are common during this period of life. The demolition of guard rails that protected against unnecessary treatments and surgeries in the past means that some currently unknown percentage of these adolescents and young adults who are being drawn to transgender and related identities will undergo unnecessary and harmful medical treatments. One result will be an increase in detransitioning and regret, as we are beginning to see.

Thus, although zealous affirmation of young people’s identities may seem an unalloyed moral good, it might have real and sometimes devastating costs. We should evaluate these historical changes and preserve some of the old safeguards or at least construct new ones, while striving to provide better care for young people struggling with gender issues, including those who will eventually transition with no later regrets.