Amid setbacks for 'gender-affirming' minor care, study on youth, gender identity is challenged

As Florida considers tightening regulations on "gender-affirming" treatments like puberty blockers and cross-sex hormones for gender-confused minors, and a British child sex change clinic is set to close following a sharply critical review, gender identity researchers are openly debating the quality of evidence for the so-called gender-affirming approach.

A buzzy new study that seeks to dispel the "social contagion" explanation for the explosion in gender-confused adolescent girls is under review in response to methodological criticisms, the American Academy of Pediatrics told Just the News.

Its journal Pediatrics is using Committee on Publication Ethics guidelines but "cannot comment further until this process is completed," spokesperson Emily Rosenbaum said.

AAP's press release for the study, which noted the 67,000-member group's support for gender-affirming care, was replaced by an error message for several hours Monday, leading to speculation it was distancing itself from the study. 

Brown University did the same in 2018 after blowback for promoting peer-reviewed research on "rapid-onset gender dysphoria" (ROGD) by its physician-researcher Lisa Littman. It tried to discredit her after Littman, who has since left, made minor corrections to the PLOS One study.

AAP's release reappeared Monday afternoon after Just the News inquired, with Rosenbaum saying it was "likely a technical glitch" and that the release hadn't been altered. It had a similar incident a year ago after recommending child masking, claiming the sudden disappearance of AAP resources on the importance of children seeing faces was the result of an unannounced website migration. 

The Pediatrics study, led by incoming University of California San Francisco child psychiatrist Jack Turban, reviewed the 2017 and 2019 Youth Risk Behavior Survey across 16 states that collect gender identity data to calculate the male-female ratio of "transgender and gender diverse (TGD) adolescents." 

It found the TGD rate dropped from 2.4% in 2017 to 1.6% in 2019, as did the absolute number of TGD-identified adolescents despite a larger group in the second survey. The male-female ratio also narrowed from 1.5 to 1 in 2017, to 1.2 to 1 in 2019, which the study blames on a reduction in participating males.

"This decrease in the overall percentage of adolescents identifying as TGD is incongruent with an ROGD hypothesis that posits social contagion," wrote the authors, whose affiliations include Harvard Medical School, Massachusetts General Hospital's psychiatry department and the Fenway Institute, an LGBTQ health and advocacy group.

TGD youth were more likely to suffer bullying and "endorse a history of suicide attempts," which argues against the "social desirability" explanation for ROGD, the study said. In light of legislative efforts to block gender-affirming treatment, the "deleterious effect of unfounded hypotheses ... cannot be overstated."

Even as it dismissed Littman's study as an "analysis of online parental survey data" and faulted its "considerable methodological limitations," Turban's study came in for criticism from otherwise sympathetic researchers in the authors' backyard.

Elle Lett, with affiliations in Boston Children's Hospital, the University of Pennsylvania's medical school and the Center for Applied Transgender Studies, led the group whose other affiliations include Boston University's medical school and Boston Medical Center's Center for Transgender Medicine and Surgery.

"While we agree with the [Pediatrics] authors that social contagion rhetoric should not be used to politically and medically argue against care provision for trans adolescents," their study has glaring methodological problems, the critical researchers wrote in a lengthy comment on the study page.

The 2017 and 2019 surveys are "insufficient for robust trend interpretation," and the study "severely misrepresents the sample," they found. The sexual orientation and gender identity module was fielded in only 10 of the 16 states in 2017 — nine with publicly available data — and 14 states in 2019, so "any differences are likely due to sampling bias, undermining trend analysis," they explained.

The critics also cited "the outsized influence of Maryland" in the findings and "disproportionate representation of states in the Northeast, with a relative dearth of other regions," as reasons to be skeptical of the study.

"[S]cience and public health as a tool of social justice requires methodological rigor in addition to conviction and intent," they wrote, calling the results "overinterpreted ... In the absence of better data, studies like this one create methodological problems for future scientists to correct." 

The email Turban provided as corresponding author bounced back when Just the News asked for a response to the critique. He didn't answer a query to his website contact form.

University of Oxford sociologist Michael Biggs alleged other problems with the study, saying it provides "considerable insight into the editorial standards maintained by Pediatrics."

The study's citations don't support its claim that youth understand "sex" to mean biological sex, according to Biggs, pointing to the youth risk survey's acknowledgment that it couldn't tell whether TGD respondents referred to their sex or gender identity.

Turban's TGD sex ratio is backwards from other American surveys from the past few years, Biggs said. An American College Health Association 2021 undergraduate survey found a male-female ratio of 0.2 to 1, a 2016 Minnesota student survey found 0.5 to 1, and a previous Pediatrics study of a California gender clinic from 2015 to 2018 found 0.4 to 1.