Lisa Littman cites Edwards-Leeper & Spack (2012) in her “rapid onset gender dysphoria” study – but did she read it?

Zinnia JonesLisa Littman’s now-notorious study on an alleged new “rapid onset gender dysphoria” condition occurring in adolescents as a result of “social contagion” (Littman, 2018) has already received extensive criticism, including but not limited to her reliance on only secondhand reports from parents recruited from anti-trans communities and the absence of any evaluation of the youth who are now being diagnosed from afar with this hypothesized condition. In several instances her analysis reveals an ignorance of or disregard for existing literature on trans youth and gender identity, in areas such as the course of trans identity development and disclosure to family, the prevalence of gender-dysphoric symptoms in adolescents, the history of the trans community’s engagement with medical gatekeeping, and the disproportionate occurrence of depersonalization disorder in untreated gender dysphoria.

However, a closer look at Littman’s paper reveals another potentially serious oversight – one involving a publication that she herself cites. Littman characterizes her proposed “rapid onset gender dysphoria” condition as generally occurring among assigned-female adolescents, presenting “suddenly” and without a known history of gender-dysphoric symptoms in childhood, and conjectures that this is the result of factors such as peer group influence and engagement with online content regarding gender transition. In introducing this supposed new phenomenon, Littman cites previous observations of an “atypical presentation” similar to her “rapid onset gender dysphoria” construct:

The majority of adolescents who present for care for gender dysphoria are individuals who experienced early-onset gender dysphoria that persisted or worsened with puberty although an atypical presentation has been described where adolescents who did not experience childhood symptoms present with new symptoms in adolescence [2, 7].

Here, Littman is citing Edwards-Leeper & Spack’s (2012) “Psychological Evaluation and Medical Treatment of Transgender Youth in an Interdisciplinary ‘Gender Management Service’ (GeMS) in a Major Pediatric Center”, which provides a review of the assessment and treatment procedures for trans youth at Children’s Hospital Boston. What “atypical presentation” do the authors describe? This section is worth citing in its entirety simply due to the extent that it addresses phenomena among these gender-dysphoric youth that Littman has presented as characteristic of an entirely new condition.

SUBSET OF LATE-ADOLESCENT ONSET TRANSGENDER PATIENTS

Most adolescent patients who are seen in the GeMS clinic report histories of gender atypical behavior and severe gender dysphoria in childhood, and their parents recall this as well. These patients would likely have met the diagnostic criteria for gender identity disorder in childhood, had we evaluated them when younger. However, there is a subset of patients who have an atypical transgender identity development for one or more reasons. Most of these late-adolescent onset transgender patients indicate that they always felt different or knew that something was not right, but were unable to identify it until puberty. Oftentimes these individuals report that they initially thought that their confusion was related to sexual orientation because they were unaware that transgenderism existed. Others report that they were aware of feeling like the other gender, but either thought that there was nothing that could be done about it so they tried to ignore the feelings, or they feared how others would react if they expressed their gender dysphoria. Some of these patients recall attempting to inform a parent of their cross-gender identity but feeling quickly dismissed or rejected, making it difficult to bring up again. We find it common among these patients to report little or no early body dissatisfaction as it relates to their male or female anatomy. Sometimes these patients report having been unaware of the anatomical differences between males and females when younger, thus being oblivious to what they were missing. The awareness of one’s body not fitting with one’s affirmed gender seems to occur at puberty for many of these patients.

Most parents of late-onset transgender patients are leery of their adolescent’s newly affirmed gender identity, this is understandable given their child’s lack of history supporting this. However, many of these adolescents report that their friends are not surprised by their declaration of their affirmed gender, often responding that they had suspected it for some time.

This paper does not support Littman’s contentions – it seriously undermines them. These observations account for a great deal of what Littman has termed “rapid onset gender dysphoria”, revealing that much or even all of the supposedly distinct features of this new condition are instead known features of classical gender dysphoria.

Is their dysphoria newly emergent or “rapid-onset”? No – these youth “always felt different or knew that something was not right, but were unable to identify it until puberty”. This is not consistent with the hypothesis of a supposed false belief of gender dysphoria suddenly emerging in a cisgender person.

Is it the case, as Littman speculates, that “experiences of same-sex attraction may also be influential in the development of a transgender identification” and that “the higher than expected rate of non-heterosexual orientations of the AYAs (prior to announcement of a transgender-identity) may suggest that the desire to be the opposite sex could stem from experiencing homophobia”? No – instead, some of these youth “initially thought that their confusion was related to sexual orientation because they were unaware that transgenderism existed”.

Is parental unawareness or surprise at a trans adolescent’s revelation of their gender identity indicative that their dysphoric symptoms must have been a recent development? No – these youth often attempt to repress their dysphoric feelings, make deliberate efforts to conceal this from their family for some time, or face outright invalidation and rejection from their parents.

Did these youth suddenly acquire gender dysphoria or a transgender identity as a result of spending time with trans friends and communities? No – just as these youth understand the need to conceal their gender from unsupportive parents, they identify and cultivate friend groups which they know will support and accept them openly as who they are.

Once again, Littman’s findings are not revelatory of a new condition – instead, her observations are exactly one what would expect to find when applying a uniquely unsuitable methodology, relying on only the perspectives of “leery” parents, to phenomena that become wholly explicable when including the perspectives and experiences of these transgender youth. It certainly does not help that, whereas Edwards-Leeper and Spack are specialists working directly with transgender youth at a major gender clinic, Littman admitted at a child and adolescent psychiatry conference earlier this year that she has never worked with any transgender clients. Has this study produced new knowledge and insight into gender dysphoria in youth – or only the extent of Lisa Littman’s own ignorance?

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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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