What the “rapid onset gender dysphoria” study missed: Timing of identity development and disclosure in LGBT youth

Since the publication of Lisa Littman’s paper on an alleged new condition called “rapid onset gender dysphoria” emerging among adolescents and young adults (Littman, 2018), many critics have pointed out the methodological flaws inherent to recruiting parents from anti-trans advocacy sites to provide information on their trans and gender-questioning kids and neglecting to assess any of these youth directly. This introduces a major sampling bias: the three sites which recruited respondents vociferously promote the notion that gender dysphoria in youth is almost always inauthentic and that transitioning is undesirable and dangerous; their spokespeople and survey respondents describe transitioning as “enslaving” and “physician-assisted self-harm”; their blog posts condemn transness itself as a “cult based on sexual fetishism and pseudoscience”; and these three sites are the very same ones that originally proposed the unproven construct of “rapid onset gender dysphoria” itself. These opinions are almost entirely contrary to a large body of evidence as well as medical professional group position statements consistently indicating that gender affirmation and transition treatment are necessary and beneficial for those with gender dysphoria.

An “ROGD parent”.

It is not particularly surprising – or informative – that individuals who are committed to believing that transness in youth is inauthentic and dangerous would respond to a survey on these beliefs in a manner consistent with these beliefs. But it is surprising that a researcher would then take this set of responses and attempt to present it as evidence that transness in youth is, in fact, inauthentic and dangerous. As Dr. Joshua Safer, spokesperson for the Endocrine Society and executive director of Mount Sinai’s Center for Transgender Medicine and Surgery, noted:

“I don’t know if there is such a thing as ROGD — a phrase that applies to the parent might be legitimate but the term ROGD is a complete overreach and it is unfair to the field. We need to limit this to what the data show us only. . . . Littman has actually written a paper about the anxiety of parents who question an open approach to transgender care and frequent sites that cast doubt on the current management approaches. No children were involved.”

However, the sampling bias inherent to recruiting respondents from avowedly anti-trans communities is not the only serious mistake in the methods and analyses of Littman’s study. Even if these parent respondents were not recruited from such groups – even if it were established that these parents were in fact unambiguously tolerant, accepting, and affirming of their trans and gender-questioning kids – the study and its findings would still be badly compromised by another major methodological error.

A shifting usage of “onset”

Littman’s proposed new construct of “rapid onset gender dysphoria” is distinguished from classical gender dysphoria by, as the name suggests, an onset of gender dysphoria that is unusually sudden:

Rapid-onset gender dysphoria (ROGD) describes a phenomenon where the development of gender dysphoria is observed to begin suddenly during or after puberty in an adolescent or young adult who would not have met criteria for gender dysphoria in childhood. ROGD appears to represent an entity that is distinct from the gender dysphoria observed in individuals who have previously been described as transgender.

She further hypothesizes that this acquisition of “ROGD” by youth is frequently influenced by a process of “social contagion”, and claims this is supported by observations of multiple individuals in friend groups coming out as trans:

Parents have described clusters of gender dysphoria outbreaks occurring in pre-existing friend groups with multiple or even all members of a friend group becoming gender dysphoric and transgender-identified in a pattern that seems statistically unlikely based on previous research. . . . Along with the sudden or rapid onset of gender dysphoria, the AYAs belonged to a friend group where one or multiple friends became gender dysphoric and came out as transgender during a similar time as they did (21.5%), exhibited an increase in their social media/internet use (19.9%), both (45.3%), neither (5.1%), and don’t know (8.2%).

The problem is that Littman repeatedly equivocates between onset of gender dysphoria and onset of transgender identification and coming out. In several instances throughout the paper, she treats these phenomena – which she variously describes as “becoming” gender-dysphoric and “becoming” transgender-identified – as if they are interchangeable:

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. . . .

Parents describe a process of immersion in social media, such as “binge-watching” Youtube transition videos and excessive use of Tumblr, immediately preceding their child becoming gender dysphoric. . . .

Rapid presentation of adolescent-onset gender dysphoria and gender dysphoria cases occurring in clusters of pre-existing friend groups is not consistent with current knowledge about gender dysphoria and has not been described in the scientific literature to date. . . .

Along with the sudden or rapid onset of gender dysphoria, the AYAs belonged to a friend group where one or multiple friends became gender dysphoric and came out as transgender during a similar time as they did (21.5%), exhibited an increase in their social media/internet use (19.9%), both (45.3%), neither (5.1%), and don’t know (8.2%).

The adolescent and young adult children were, on average, 14.4 years old when their first friend became transgender-identified (Table 6). . . .

One of the most compelling findings supporting the potential role of social and peer contagion in the development of a rapid onset of gender dysphoria is the cluster outbreaks of transgender-identification occurring in friendship groups.

Is Littman describing a “rapid onset” of gender dysphoria in youth, or a “rapid presentation” of gender dysphoria? Did the friends of these youth “become gender-dysphoric”, or did they “become transgender-identified”? This is not a small issue: experiencing symptoms of gender dysphoria and adopting a transgender identity are not at all the same thing, nor do these milestone events typically happen at the same time. At a minimum, this inaccurate and misleading phrasing (whether intentional or unintentional) requires correction. Further, the time at which a parent became aware of a child’s gender dysphoria or transgender identity is not at all synonymous with the time at which gender-dysphoric symptoms or transgender identity first emerged in these youth.

Parental awareness is distinct from onset of gender dysphoria

Littman appears to believe that the parent responses to her survey regarding their prior unawareness of a child’s gender dysphoria are notable and unusual enough to be indicative of a new condition:

For the purpose of this study, rapid-onset gender dysphoria (ROGD) is defined as a type of adolescent-onset or late-onset gender dysphoria where the development of gender dysphoria is observed to begin suddenly during or after puberty in an adolescent or young adult who would not have met criteria for gender dysphoria in childhood. … Most of the parents (80.9%) answered affirmatively that their child’s announcement of being transgender came “out of the blue without significant prior evidence of gender dysphoria.” Respondents were asked to pinpoint a time when their child seemed not at all gender dysphoric and to estimate the length of time between that point and their child’s announcement of a transgender-identity. Almost a third of respondents (32.4%) noted that their child did not seem gender dysphoric when they made their announcement and 26.0% said the length of time from not seeming gender dysphoric to announcing a transgender identity was between less than a week to three months.

However, a parent’s perception of whether their child “seemed not at all gender dysphoric” may not be indicative of whether their child is gender-dysphoric. The DSM-5 description of gender dysphoria recognizes that both those assigned male and assigned female may not express these symptoms openly, and that as a result, parents may be surprised when transgender youth come out in adolescence (American Psychiatric Association, 2013):

Late-onset gender dysphoria occurs around puberty or much later in life. Some of these individuals report having had a desire to be of the other gender in childhood that was not expressed verbally to others. Others do not recall any signs of childhood gender dysphoria. For adolescent males with late-onset gender dysphoria, parents often report surprise because they did not see signs of gender dysphoria during childhood. Expressions of anatomic dysphoria are more common and salient in adolescents and adults once secondary sex characteristics have developed. . . .

The late-onset form is much less common in natal females compared with natal males. As in natal males with gender dysphoria, there may have been a period in which the gender dysphoria desisted and these individuals self-identified as lesbian; however, with recurrence of gender dysphoria, clinical consultation is sought, often with the desire for hormone treatment and reassignment surgery. Parents of natal adolescent females with the late-onset form also report surprise, as no signs of childhood gender dysphoria were evident. Expressions of anatomic dysphoria are much more common and salient in adolescents and adults than in children.

And the clinical experience of gender therapists, such as Elijah C. Nealy, LCSW, reflects this common and well-known pattern of adolescent secrecy and parental surprise (Nealy, 2017):

Historically, the acceptable narrative for transgender people required an awareness of gender dysphoria as a child. In recognizing the possibility of late-onset dysphoria, DSM-5 acknowledges the reality that some adolescents (and adults) may not recall earlier gender dysphoria and may not have verbalized or manifested the associated symptoms. When the latter is true, many parents are surprised to hear about their adolescent’s gender dysphoria or their longing to live in their affirmed gender. The fact that these parents did not see it (the trans identity) coming may lead them to suspect that their adolescent’s reported trans identity is not valid or “real”.

Many clinicians as well believe that the onset of gender dysphoria always occurs during childhood and are unfamiliar with late-onset gender dysphoria. Consequently, they too may have difficulty believing the teen’s recent report of gender dysphoria or announced transgender identity and possible desire to transition. Both parents and mental health providers sometimes view late-onset gender dysphoria in adolescents as a phase or developmentally normative identity exploration that will desist over time. If so, they may not allow the adolescent to transition – even socially, when there are no irreversible medical interventions. . . .

It is useful for therapists to explore these areas with parents of teens as well, although their ability to do this may depend on the context of their practice setting. It is possible that a parent’s experience of their child or adolescent in terms of gender identity may vary from the young person’s experiences and sense of themselves. When this is true, it is possible that the young person’s internal sense of themselves was not apparent to those around them. It could also be that the young person’s description of their interests and/or behavior occurred primarily with peers and not within the family.

If one were to survey only the parents of these children without asking the youth themselves, they may very well report that their child’s revelation “came ‘out of the blue without significant prior evidence of gender dysphoria’”, or that “their child did not seem gender dysphoric when they made their announcement”. And these parents could be entirely honest in stating that their child “did not seem gender dysphoric” – to them. But it does not therefore follow that a child actually was not gender-dysphoric until such time as their parent became aware of this.

These aspects of transgender self-awareness and disclosure are not only a matter of clinical experience, but of quantitative evidence. Studies indicate that trans youth typically go through a years-long process of becoming aware of their gender-dysphoric or gender-variant feelings, followed by recognizing what these feelings mean and adopting an identity as trans, and finally by disclosing their transness to others such as their parents.

• Grossman et al. (2005) observed that in a sample of 55 trans girls and boys aged 15 to 21, the trans boys reported “feeling different from others” at a mean age of 7.5 years, and trans girls at 7.6 years. However, these youth did not consider themselves transgender until much later: trans boys at an average age of 15.2 years, and trans girls at 13.4 years. Finally, trans boys first told someone else they were transgender at an average age of 17 years, and trans girls at 14.2 years.
• Grossman & D’Augelli (2006) studied 24 trans youth aged 15 to 20, and found that these youth “first became aware that their gender identity or gender expression did not correspond to their biological sex” at an average age of 10.4 years. They did not label themselves transgender until an average age of 14.3 years, and did not first disclose their gender identity to someone else until an average age of 14.5 years.

This is consistent with the sequence of milestones observed in lesbian, gay, and bisexual identity development and disclosure. Heck et al. (2013) found that among 79 lesbian, gay, bisexual, or transgender college students who had attended a high school with a gay-straight alliance, they first began questioning their identity at an average age of 12.8 years, labeled themselves with this identity at 15.2 years, and first disclosed their identity to others at 15.7 years. Maguen et al. (2002) observed that in a sample of 117 lesbian, gay, and bisexual adolescents and young adults, they first became aware of their attraction at an average age of 10.9 years, but only disclosed this to others at an average age of 16.6. And Calzo et al. (2011) surveyed 1,260 lesbian, gay, and bisexual adults aged 18 to 84, finding an average age of 14.8 years for first awareness of their attractions, 19.7 years for first self-identification as LGB, and 23.9 years for coming out to others.

The notion that parents would reliably possess a clear awareness of their child’s gender identity or sexual orientation prior to these youth coming out to them is simply not supported by the existing literature. And that lack of awareness certainly does not therefore mean that these youth were not actually trans or queer until their parent first learned of this.

What this means for “rapid onset gender dysphoria” and “social contagion”

There is ample evidence indicating that parental awareness of a child’s gender dysphoria or transgender identity is not a reliable proxy for the actual history of that child’s gender-dysphoric symptoms of transgender identity development. Many trans youth are known to be aware of their feelings of gender dysphoria and gender variance for years before disclosing this to parents or others – even the most supportive of parents may report that their trans child did not “seem” gender-dysphoric at the time they came out.

By relying wholly on parent-reported awareness, Littman is likely generating incorrect data regarding the development and course of gender dysphoria in these youth. This likely incorrect data constitutes the very basis for proposing “rapid onset” of gender dysphoria as a new and distinct condition. There is substantial reason to believe that this supposed “condition” is in fact entirely illusory and a mere artifact of Littman’s poor choice of methodology.

This is even more applicable to her claims regarding a “socially contagious” spread of “ROGD” within friend groups or via internet usage. Littman presents remarkably specific data on this supposed phenomenon:

Along with the sudden or rapid onset of gender dysphoria, the AYAs belonged to a friend group where one or multiple friends became gender dysphoric and came out as transgender during a similar time as they did (21.5%), exhibited an increase in their social media/internet use (19.9%), both (45.3%), neither (5.1%), and don’t know (8.2%). . . . The adolescent and young adult children were, on average, 14.4 years old when their first friend became transgender-identified (Table 6). Within friendship groups, the average number of individuals who became transgender-identified was 3.5 per group. In 36.8% of the friend groups described, the majority of individuals in the group became transgender-identified. The order that the focal AYA “came out” compared to the rest of their friendship group was calculated from the 119 participants who provided the number of friends coming out both before and after their child and 74.8% of the AYAs were first, second or third of their group.

A parent’s report of their awareness of when their own child “became gender-dysphoric” is already known to be highly questionable as an accurate source of information on when their child actually did begin to experience gender-dysphoric symptoms. How is it that these parents can then be assumed to be reliable informants regarding the development of gender-dysphoric symptoms in other people’s children as well? And if, as we know, such parental reports regarding their own children’s gender dysphoria are not reliable, how can the data collected in this manner serve as a sufficient basis to propose some mechanism of transgender “social contagion” occurring between friends?

This unsupported and highly questionable assumption that the parents surveyed are nearly all-knowing is the foundation for a variety of other claims by Littman regarding the supposed acquisition of “ROGD” by reading about transgender topics on the internet. Witness the extraordinary level of detail reported here:

Parents describe a process of immersion in social media, such as “binge-watching” Youtube transition videos and excessive use of Tumblr, immediately preceding their child becoming gender dysphoric. . . . In the time period just before announcing that they were transgender, 63.5% of AYAs exhibited an increase in their internet/social media (Table 7). To assess AYA exposure to existing online content, parents were asked what kind of advice their child received from someone/people online. AYAs had received online advice including how to tell if they were transgender (54.2%); the reasons that they should transition right away (34.7%); that if their parents did not agree for them to take hormones that the parents were “abusive” and “transphobic” (34.3%); that if they waited to transition they would regret it (29.1%); what to say and what not to say to a doctor or therapist in order to convince them to provide hormones (22.3%); that if their parents were reluctant to take them for hormones that they should use the “suicide narrative” (telling the parents that there is a high rate of suicide in transgender teens) to convince them (20.7%); and that it is acceptable to lie or withhold information about one’s medical or psychological history from a doctor or therapist in order to get hormones/get hormones faster (17.5%).

These brief descriptions disguise some very broad claims. How many parents keep track of the online activities of their children – aged 11 to 27 – in such painstaking detail? Is it indeed the case that these hundreds of parent respondents so closely monitor their children’s usual patterns of internet usage; the specific points in time that their children began to explore certain topics online; the overall trends in their children’s browsing of various subject areas over time such that they can meaningfully characterize these patterns of internet activity as a “binge”; and the totality of what their children are looking at online in home, school, and social settings – up to age 27? This strains belief given how many parents are wholly unaware of even their own child’s gender identity.

Moreover, published literature already recognizes that online content can play a significant role in helping sexual minority youth put a name to their feelings (Gray, 2009):

‘‘I first started noticing that I was attracted to other girls when I was about 12 or 13. Before then, I can’t even say that I knew gay people existed. But even when I was young I watched girls on TV and was amazed by them. I was over at my friend’s house one night joking that I only watched Baywatch (my favorite show at the time) for the girls. After I said this, I realized it was true. It wasn’t until about a year later, when I got on the Internet and found other people like me that I actually said to myself that I was bisexual. I’ve always been attracted to both sexes, but I found my true identity on the Internet.’’–Amy, age 15. . . .

Darrin, a gay-identifying 17-year-old from an agricultural town of 6,100 people sees web sites, like the commercial portal, PlanetOut.com, as, ‘‘a place to feel at least somewhat at home.’’ He adds, ‘‘but then I have to figure out how to make that home here too, you know? Chat rooms give me a place to go when I don’t feel I can connect to others where I am.’’ Amanda, a 14-year-old from Kentennessee, describes her experiences online as ‘‘pretty much the only place I can Google stuff or say my true feelings and not have everyone know about it.’’ Darrin and Amanda’s mention of commercial LGBTQ portals and search engines suggest that these genres offer a boundary public—a sense of place and the tools to find more resources—for their identity work.

Does this mean that these youth had not experienced same-sex attractions until their engagement with this online content somehow caused them to have these feelings? Of course not. Yet Littman would have us believe that trans youth, who often spend years being aware of their feelings before labeling themselves or coming out, have actually acquired gender dysphoria by browsing online content relevant to their identity work and development.

This is the central flaw of “rapid onset gender dysphoria” as an alleged condition supported by the findings of this study: the methods and analyses treat a parent’s imperfect subjective perception and awareness of another person’s inner life as instead offering the final word on that person’s gender identity and gender dysphoria. The study offers this argument in the face of substantial literature studying the identity development processes of gender and sexual minority youth. Much of this is quite obvious to those who already understand the difficulty of navigating this arduous process, of trying to make sense of one’s gender-variant feelings with whatever resources are on hand, of negotiating when or if to come out to family members whose reactions may be unaccepting or even dangerous. But when you entirely forgo any engagement with trans people themselves and instead choose only to study this from the perspective of an outside observer, that’s all you’re going to get: the perspective of an outside observer.

It is striking to witness proponents of “ROGD” set themselves to the task of studiously ignoring what’s been widely known for decades: that LGBT youth often have every reason to stay closeted and hide their identities from their families until a time of their choosing. Such disregard for reality may be necessary to maintain the vitality of the deeply flawed theory that they’ve committed themselves to believing. But that is not how science is done. ■

References

• American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing. [Excerpt]
• Calzo, J. P., Antonucci, T. C., Mays, V. M., & Cochran, S. D. (2011). Retrospective recall of sexual orientation identity development among gay, lesbian, and bisexual adults. Developmental Psychology, 47(6), 1658–1673. [Full text]
• Gray, M. L. (2009). Negotiating identities/queering desires: coming out online and the remediation of the coming-out story. Journal of Computer-Mediated Communication, 14, 1162–1189. [Full text]
• Grossman, A. H., D’Augelli, A. R., Howell, T. J., & Hubbard, S. (2005). Parents’ reactions to transgender youths’ gender nonconforming expression and identity. Journal of Gay & Lesbian Social Services, 18(1), 3–16. [Abstract]
• Grossman, A. H., & D’Augelli, A. R. (2006). Transgender youth: invisible and vulnerable. Journal of Homosexuality, 51(1), 111–128. [Abstract]
• Heck, N. C., Lindquist, L. M., Stewart, B. T., Brennan, C., & Cochran, B. N. (2013). To join or not to join: gay-straight student alliances and the high school experiences of lesbian, gay, bisexual, and transgender youths. Journal of Gay & Lesbian Social Services, 25(1), 77–101. [Abstract]
• Littman, L. L. (2018). Rapid-onset gender dysphoria in adolescents and young adults: a study of parental reports. PLOS ONE, 13(8), e0202330. [Full text]
• Maguen, S., Floyd, F. J., Bakeman, R., & Armistead, L. (2002). Developmental milestones and disclosure of sexual orientation among gay, lesbian, and bisexual youths. Applied Developmental Psychology, 23, 219–233. [Abstract]
• Nealy, E. C. (2017). Transgender children and youth: Cultivating pride and joy with families in transition. New York, NY: W. W. Norton & Company. [Google Books]