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On August 16, 2018, Lisa Littman, an assistant professor at Brown University, published a study in PLOS One titled “.” It defined the term rapid-onset gender dysphoria (ROGD) as gender dysphoria appearing rapidly around the time of puberty in adolescents and young adults who would not have met the criteria for gender dysphoria in childhood. It suggested that ROGD could be due to social contagion (peer pressure and online influences) rather than to an innate, immutable sense of incongruence between anatomical sex and personal sense of gender.

A huge kerfuffle ensued. Brown removed the news about the study from its website because of (1) concerns about its methodology and (2) concerns that the conclusions of the study could be used to discredit efforts to support transgender youth. The PLOS One account was mobbed by transgender activists who disputed the existence of ROGD, and the journal promised to do a postpublication investigation. An quickly garnered thousands of signatures urging Brown and PLOS One to “resist ideologically-based attempts to squelch controversial research evidence.”

Previous studies

Previous studies had mainly dealt with children whose gender dysphoria started in childhood. There were no studies of people whose gender dysphoria appeared rapidly around the time of puberty. One study in Finland did shed some light on the subject. In Finland, a psychiatric assessment by a specialized gender identity team is a prerequisite for legal as well as surgical gender reassignment, both of which have a lower age limit of 18. at two university gender identity clinics had some surprising findings:

  • In patients seeking reassignment, there was a preponderance of natal females (41 vs 6), whereas They had no explanation for the female preponderance in their clinics.
  • Only 32% had started to consciously question their gender before the age of 12
  • 72% were sure about their identity and their desire for gender reassignment, 28% were unsure.
  • Of those who were sure, only 15% reached that conclusion before the age of 12.
  • 57% had been bullied, but only 27% of bullying was related to gender issues.
  • 75% of applicants were under psychiatric care for reasons unrelated to gender: depression (64%), anxiety (55%), suicidal and self-harming behaviors (53%), psychotic symptoms (13%), autism (26%) and smaller numbers for conduct disorders, substance abuse, and ADHD.
  • Social isolation was the strongest factor predicting membership of the problematic, identity confused group.
  • The number of patients was greater than expected, suggesting that gender dysphoria may be more common among adolescents than among adults, or it may be increasing in younger age cohorts.
  • Only about half of gender dysphoric patients presented with an established transsexual identity.

They found that “In the majority of the applicants, gender dysphoria presented in the context of wider identity confusion, severe psychopathology and considerable challenges in the adolescent development.”

They concluded:

Adolescents seeking sex reassignment represent a variety of developmental pathways differentiated by the timing of onset of gender dysphoria, psychopathology and developmental difficulties. It is important to be aware of the different groups, or developmental pathways, in gender dysphoric adolescents in order to be able to find appropriate treatment options. In the presence of severe psychopathology and developmental difficulties, medical SR treatments may not be currently advisable. Treatment guidelines need to be reviewed extended [sic] to appreciate the complex situations.

The controversial PLOS One study

Here’s how Littman described the purpose of her study:

In on-line forums, parents have been reporting that their children are experiencing what is described here as “rapid-onset gender dysphoria,” appearing for the first time during puberty or even after its completion. The onset of gender dysphoria seemed to occur in the context of belonging to a peer group where one, multiple, or even all of the friends have become gender dysphoric and transgender-identified during the same timeframe. Parents also report that their children exhibited an increase in social media/internet use prior to disclosure of a transgender identity. The purpose of this study was to document and explore these observations and describe the resulting presentation of gender dysphoria, which is inconsistent with existing research literature.

Littman created a 90-item questionnaire for parents with gender-dysphoric adolescent or adult children and recruited volunteer parents from three websites where rapid onset gender dysphoria had been described. Respondents were asked to share the link to the questionnaire with other eligible participants. 256 completed surveys were analyzed. In addition to specific questions, parents were encouraged to describe their experiences.

The study reported a mass of data. Some of the findings:

  • The children in question were predominantly natal females.
  • Gender dysphoria began during puberty for 49% and after puberty for 51%.
  • 69% of children were part of a friend group where one or more friends has come out as transgender; 65% had an increase in social media/internet use; 45% both belonged to a friend group and increased internet use.
  • 2.7% had taken puberty blockers, and 2% had had surgery.
  • The majority (77%) of the surveyed parents felt that their child was incorrect in their belief of being transgender.
  • Parents felt that clinicians had not adequately evaluated the child and had failed to explore mental health, trauma, or alternative causes of gender dysphoria.
  • 62.5% reported that the child had misrepresented information to the clinician.
  • 22.3% had been exposed to online advice about what to say to doctors to get hormones, and 17.5% to the advice that it is OK to lie to physicians.
  • Some reported that transition steps were pushed by the clinician. 24% of the parents who knew the content of their child’s visit reported that the child was offered prescriptions for puberty blockers and/or cross-sex hormones at the first visit.
  • 35% of natal females and 56% of natal males expressed their sexual orientation as heterosexual prior to announcement. About a quarter had not expressed a sexual orientation. The rest were asexual, bisexual, or gay.
  • 3% reported that the child was already backing away from transgender identification. One said that after a year of identifying as transgender, her daughter changed her mind after she stopped spending time with that particular group of friends.
  • 47% of children were categorized by the parents as “gifted.” To my mind, that demonstrates the unreliability of parent reports. It reminds me of Lake Wobegon, where “all the children are above average.”

Littman described two hypotheses arising from the data:

  • Social contagion is a key determinant of ROGD.
  • ROGD is a maladaptive coping mechanism.

She says if these hypotheses are true, ROGD that is socially mediated or used as a maladaptive coping mechanism may harm these adolescents and young adults in several ways: non-treatment for mental health problems, alienation from parents and support systems, isolation from mainstream, non-transgender society, and the medical and surgical risks of transition.

Littman acknowledges that the study is a descriptive one designed to raise awareness of the previously unrecognized specific population of ROGD and to generate hypotheses; it was not designed to measure prevalence. To counter the possibility that the parents who responded were more likely than the average parent to have anti-transgender sentiments, they were asked if they believed transgender people deserve the same rights and protections as others; 88.2% answered “yes” which is consistent with the affirmative response in a US national poll.

Her conclusion:

Rapid-onset gender dysphoria describes a phenomenon where the development of gender dysphoria is observed to begin suddenly during or after puberty in an adolescent or young adult (AYA) who would not have met criteria for gender dysphoria in childhood. ROGD appears to represent an entity that is distinct in etiology from the gender dysphoria observed in individuals who have previously been described as transgender. It is plausible that ROGD represents an ego-syntonic maladaptive coping mechanism for some AYAs and that peer group and online influences may contribute to its development. It is unknown whether the gender dysphoria of rapid-onset gender dysphoria is temporary or likely to be long-term. The elevated number of friends per friendship group who became transgender-identified, the pattern of cluster outbreaks of transgender-identification in these friendship groups, the substantial percentage of friendship groups where the majority of the members became transgender-identified, and the peer group dynamics observed all serve to support the plausibility of social and peer contagion for ROGD. The worsening of mental well-being and parent-child relationships and behaviors that isolate teens from their parents, families, non-transgender friends and mainstream sources of information are particularly concerning. More research is needed to better understand rapid-onset gender dysphoria, its implications, and scope.

Criticisms of the study

There are many things wrong with this study. The data was collected from parents who reported ROGD in their children. Studying the children themselves might have revealed that the onset was not as rapid as the parents thought, so the study really did nothing to establish the validity of the ROGD category. The sample was biased: responders were self-selected from websites that accepted the concept of ROGD. The fact that 76.5% believed their child’s gender beliefs were wrong is worrisome, to say the least. The fact that they said they support transgender rights doesn’t mean that they are not biased against transgender people in other ways. Most of the respondents were mothers; might fathers or other family members or independent observers have answered differently? Selection of participants was not systematic, and there was no attempt to provide controls or randomization. Parental reports are not reliable. Parents may not know as much about their children as they think; and indeed, 8.6% reported that they didn’t even know if their child was currently transgender-identified. There was no way to verify the accuracy of their answers. Their answers may be influenced by a desire to give the “correct” answers and by wishful thinking; I can’t believe that half of these children are “gifted.”

In defense of the study

Littman’s interest in the subject arose from anecdotal reports on social media. Anecdotes are not acceptable as scientific data, but they are useful for identifying things that are worth studying scientifically. Late-onset gender dysphoria was recognized, but ROGD seemed to be a new category. She did a study that was exploratory and hypothesis-generating. She did not accuse transgender adolescents of being pressured into following a fad; she raised questions. She said more research is needed, and . She is currently studying parent/teen pairs where the gender dysphoria resolved in one to three years without medical treatment and she is “analyzing data from a survey of 100 people who experienced gender dysphoria, chose to undergo medical or surgical transition, and then de-transitioned by stopping hormone treatment or having surgery to reverse the effects of transition”.

Suppressing controversial evidence

In my opinion, Brown University was wrong to remove the information about this study from their website. They gave two reasons for it. The first reason was the study’s poor methodology. There are thousands of other published studies with poor methodology, some of them with far worse methodology than this one, some of which have been eviscerated on Private-investigator-detective. Editors and peer reviewers could prevent the publication of fatally flawed studies, and journals can retract articles. But if an article has not been retracted by the editors of the journal, suppression by others is not the answer; who could we trust with censorship power and how could we be certain they were unbiased? Science is a collaborative process that requires transparency and open discussion. Brown could have simply added a statement to their website saying that the methodology of this study had been questioned and they could have provided links to the criticisms. Have they removed any other studies from their website on the basis of poor methodology alone?

The second reason was “concerns that the conclusions of the study could be used to discredit efforts to support transgender youth”. I don’t think evidence should ever be suppressed because of fears that some people might mis-use it. If a study shows that a disease is more common in a certain racial group, should that information be suppressed because it might reinforce racism? In my opinion, it was unreasonable for Brown to remove the study to appease those who objected for ideological reasons on one side of a very controversial issue.

Conclusion: Food for thought

Despite its flaws, Littman’s study is valuable in that it raises important questions. If even a handful of children are being unduly influenced by peer pressure and media, if dysphoria doesn’t always persist, if even a handful of treated people later feel the need to reverse their transitions, we want to understand what is happening. We want to try to find ways to better help each individual and to predict whose dysphoria will last. The high incidence of mental health issues in gender dysphoric patients is worrisome; is it possible that adequate treatment of those issues might resolve the gender dysphoria for some of them?

Transgender issues evoke strong emotions. There are transgender denialists who think gender dysphoria is delusional and should not be condoned. Some of those who accept gender dysphoria think it is socially determined; others think it is biologically determined. Some advocate gender transition treatments at an early age to minimize suffering and reduce risks like suicide; others advocate delay and caution. A subgroup of feminists, (TERFs), are strongly opposed to transgender identities, experiences, and rights. Some feminists see female-to-male transitions as surrenders to male oppression and believe that if society treated males and females fairly, there would be no reason for gender dysphoria to exist.

More and more people, children and adults, are reporting gender dysphoria and seeking gender transition; and if we are to serve their best interests, we need to know more. We can only know more through well-designed studies, which this is not. It has not even been established that ROGD is a meaningful category. I await further, better-designed studies with great anticipation.

Correction

There were some errors in the article as originally posted. WordPress inexplicably deleted the numbers to the left of the decimal point. They have been corrected.

2.7% had taken puberty blockers, not 7%
22.3% had been exposed to online advice about what to say to doctors to get hormones, not 3%
23.8% said doctors had offered puberty blockers at the first visit, not 8%
35.4% of natal females expressed their sexual orientation as heterosexual prior to announcement, not 4%
2.7% had been backing away from transgender identification, not 7%
62.5% had misrepresented information to the clinician, not 5%
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Posted by Harriet Hall

Harriet Hall, MD also known as The SkepDoc, is a retired family physician who writes about pseudoscience and questionable medical practices. She received her BA and MD from the University of Washington, did her internship in the Air Force (the second female ever to do so),  and was the first female graduate of the Air Force family practice residency at Eglin Air Force Base. During a long career as an Air Force physician, she held various positions from flight surgeon to DBMS (Director of Base Medical Services) and did everything from delivering babies to taking the controls of a B-52. She retired with the rank of Colonel.  In 2008 she published her memoirs, .