“Rapid onset gender dysphoria” study omits historical context of transgender narratives and medical gatekeeping

The full “rapid onset gender dysphoria” study, published this month, goes into further detail about the hypothesized acquision and spread of this allegedly “socially contagious” condition. The study’s author, Lisa Littman, proposes that online content from transgender support communities may be encouraging non-transgender youth to believe falsely that they are trans and gender-dysphoric:

On the one hand, an increase in visibility has given a voice to individuals who would have been under-diagnosed and undertreated in the past [36]. On the other hand, it is plausible that online content may encourage vulnerable individuals to believe that nonspecific symptoms and vague feelings should be interpreted as gender dysphoria stemming from a transgender condition. Recently, leading international academic and clinical commentators have raised the question about the role of social media and online content in the development of gender dysphoria [37]. Concern has been raised that adolescents may come to believe that transition is the only solution to their individual situations, that exposure to internet content that is uncritically positive about transition may intensify these beliefs, and that those teens may pressure doctors for immediate medical treatment [18]. There are many examples on popular sites such as Reddit (www.reddit.com with subreddit ask/r/transgender) and Tumblr (www.tumblr.com) where online advice promotes the idea that nonspecific symptoms should be considered to be gender dysphoria, conveys an urgency to transition, and instructs individuals how to deceive parents, doctors, and therapists to obtain hormones quickly [38].

Figure 1 of her paper provides only three Reddit comments as an example of “instructions on lying” in order to obtain gender-affirming treatment. But even if there were more substantial evidence that a tendency toward this practiced deception is present among trans youth, this would not be at all characteristic of a new kind of gender dysphoria. Why? Because the need for trans people to craft their narratives carefully in order to meet the approval of clinical standards has been a feature of the interaction between trans people and clinicians since at least the 1960s.

Trans people have long had a motivation to make their personal stories as acceptable as possible in order to be accepted for gender-affirming care: they needed treatment for their gender dysphoria, yet clinical expectations frequently required conforming to unrealistically exaggerated gender stereotypes as a precondition for accessing that treatment. In a 1971 paper, physician Robert Stoller characterized trans women as “developing a feminine gracefulness of movement” as children, avoiding any relationships or sexual contact with women in adulthood, “avoiding masturbation”, and having a “lifelong identification with femininity and feminine roles”. In Stoller’s conception, trans women are expected to have relationships with heterosexual men only. His expectations for trans men are just as exaggerated in their gender stereotyping: they are said to take an interest in hunting, fishing, playing sports, carpentry, and farming, and generally identify with the “masculine interests” of their father. Trans men, too, are expected to be “exclusively heterosexual” and only have relationships with women who are “unfailingly heterosexual”.

How stringent were these standards in clinical practice? Stoller explains: “Only those rare patients who fulfill the criteria described above – the most feminine of males and the most masculine of females – should undergo sex transformation.”

Faced with such an extraordinarily high bar – one that would certainly invalidate the womanhood of many cis women and the manhood of many cis men – trans people didn’t retreat. They regrouped, collaborated, and figured out exactly how to work within this system, learning what these clinicians expected to hear. By 1968, doctors at Johns Hopkins were already aware of this community spread of narrative-crafting, stating:

“In data from interviews a high degree of patient motivation to obtain surgery is noted. Patients tend to skew memory and report only those feelings of belonging to the opposite gender. … Throughout the interview the patient’s strong desire to be accepted in the acquired gender role and the prospect of secondary gain may be expected to strongly influence the response to questions.”

Robert Stoller further observed that “most patients requesting ‘sex change’ are in complete command of the literature and know the answers before the questions are asked”, and Dr. Norman Fisk reported:

“…virtually all patients who initially presented for screening provided us with a totally pat psychobiography which seemed almost to be well rehearsed or prepared… it was apparent that this group of patients were so intent upon obtaining sex conversion operations that they had availed themselves of the germane literature and had successfully prepared themselves to pass initial screening.”

Compare this to Littman’s observations from surveyed parents:

Of the 51 responses describing reasons why respondents thought their child was reproducing language they found online, the top two reasons were that it didn’t sound like their child’s voice (19 respondents) and that the parent later looked online and recognized the same words and phrases that their child used when they announced a transgender identity (14 respondents). The observation that it didn’t sound like their child’s voice was also expressed as “sounding scripted,” like their child was “reading from a script,” “wooden,” “like a form letter,” and that it didn’t sound like their child’s words. Parents described finding the words their child said to them “verbatim,” “word for word,” “practically copy and paste,” and “identical” in online and other sources. The following quotes capture these top two observations. One parent said, “It seemed different from the way she usually talked—I remember thinking it was like hearing someone who had memorized a lot of definitions for a vocabulary test.” Another respondent said, “The email [my child sent to me] read like all of the narratives posted online almost word for word.” …

One participant wrote, “At [the] first visit, [my] daughter’s dialogue was well-rehearsed, fabricated stories about her life told to get [the] outcome she desired. She parroted people from the internet.” Another parent reported, “My son concealed the trauma and mental health issues that he and the family had experienced.” And a third parent said, “I overheard my son boasting on the phone to his older brother that ‘the doc swallowed everything I said hook, line and sinker. Easiest thing I ever did.’”

What Littman is describing here is not new – it is simply an adaptation of a known phenomenon to the digital age. If this behavior has been known to occur among trans people since the 1960s, it is not at all specifically characteristic of some kind of newly-emergent syndrome of gender dysphoria.

But what of the underlying concern here – that these crafted narratives will lead to the false presentation of gender dysphoric symptoms, false diagnosis of gender dysphoria in people who are actually cisgender, and unnecessary and inappropriate treatment for this population? This fear has not been borne out by the evidence. Even as many trans people across decades have been familiar with the need to present a certain acceptable story to clinicians, a study of all trans people who presented for treatment in Sweden from 1960 to 2010 found a rate of regret of only 2.2%. Even if it were the case that some number of these patients presented altered stories to obtain treatment, this does not seem to have led to a proliferation of false diagnosis and inappropriate treatment.

The findings Littman presents are no more ominous: even given her substantially biased sample of survey respondents, her results showed that 83.2% of the children of parents surveyed had at least two indicators of adolescent and adult gender dysphoria, meeting the criteria for diagnosis. And over an average span of 15 months, only 5.5% of these youth desisted from a transgender identity. Transgender narrative-crafting to access transition treatment is not new, does not appear to be associated with poor outcomes, and certainly does not require proposing a wholly new condition in order to explain this phenomenon. 

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About Zinnia Jones

My work focuses on insights to be found across transgender healthcare, public health, psychiatry, and history of medicine, integrating these many perspectives and guided by the lived experiences of trans people. I live in Orlando with my family, and work mainly in technical writing.
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