Origin and scope of the “rapid onset gender dysphoria” (ROGD) pseudo-diagnosis of trans youth
The proposed condition of ROGD thus suggests that, as apparent trans adolescents may actually be misdiagnosed cis youth, the effective gender-affirming treatment given as a standard of care for trans youth would be inappropriate or harmful for this group of youth, and so this gender-affirming treatment should be withheld from them.
Following Littman’s 2018 study, this claimed condition has been widely promoted in the public discourse by anti-trans advocacy groups, right-wing legal groups, conservative legislators, “intellectual dark web” commentators, and those of any stripe whose politics include the invalidation of trans youth. The spectre of this contagion of mistaken gender running rampant among youth has recently been the subject of alarm among Republican lawmakers, as always under the banner of “protecting children”, working to ban access to medical transition for trans adolescents – and in at least one state succeeding.
Littman’s study has a fundamental flaw in its methodology that broadly undermines its reported findings. According to Littman, a key feature distinguishing ROGD from classic gender dysphoria is that ROGD appears very quickly in a child who was heretofore apparently cisgender with no sign of gender incongruity. The observations of this rapidity consisted entirely of reports from anonymous parents on their own perception of their child’s gender identity and development, almost universally expressing surprise at the sudden nature of their child’s statement of a transgender identity. The youth themselves were not surveyed on their own experiences of gender incongruity throughout their childhood, how long they had experienced gender incongruity or considered themselves transgender, or how long they had waited to make their trans identity visible to these parents for the first time.
These secondhand parental observations are the only evidence offered by Littman for the distinct “rapid” nature of the progression of ROGD, unlike classic gender dysphoria, which we can infer that Littman considers to have a more complex or protracted course of development and consideration. There is a problem: In this area, parental reports of their child’s gender development are not sufficient to make the case that their child actually has experienced a “rapid onset”. Extensive existing literature over decades has already shown that many parents do experience surprise at a trans child coming out; at the same time, their child gave much thought to their gender and identity for many years before that. The converse of parents’ surprise is the consistent finding, when trans youth and adults are the ones asked, that several years can pass as we contemplate our gender in our childhood and take our time before deciding when we come out as trans.
These two sets of observations occur because trans people have access to our own internal experiences and perceptions of gender while our parents can only access what we voluntarily express externally. Littman’s mistake in formulating ROGD is treating the latter as though it defines the former, with a child’s actual gender development being collapsed into a parent’s own perception, one necessarily narrowed down to the first time we chose to be visible. Treating parental observations as synonymous with actual child gender development processes is unsupported and contradicted by nearly every other published study in this area.
One notable study recently acquired the information Littman’s study conspicuously lacked, surveying both trans youth and their parents or caregivers on their reports of their own gender self-recognition and disclosure milestones versus their caregivers’ perception of the timing and pace of their gender development milestones. The discrepancy between parent perceptions and trans youth’s identity development has been quantified and it is a significant difference.
ROGD’s methodological error: Using parent perceptions to equivocate between trans youth’s self-recognition and disclosure
In July 2017 I had already pointed out the insufficiency of Littman’s reliance on parental reports as a proxy for youth’s gender identity development, and in February 2018 I explained why this methodology ran the risk of producing highly biased results:
This is a crucial gap: these children have not been administered any validated survey instruments on gender dysphoria, mental health, social functioning, or anything that would serve to demarcate this “new” condition from the traditional form of gender dysphoria currently observed among youth. Parent reports of a “rapid” onset of dysphoria are especially questionable: many trans youth understandably conceal their identities for years, knowing the consequences of coming out to potentially unaccepting parents could be dire. What appears to a parent to be a “rapid” onset may not have been rapid for their child at all, and it is common in trans support forums to hear from youth (and adults) whose parents protest that they “never showed any signs”.
Dr. Joshua Safer of the Endocrine Society and Mount Sinai’s Center for Transgender Medicine likewise explained that Littman’s study of what she calls ROGD actually only consists of a survey of parents’ perceptions and attitudes:
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.
Even the DSM-5 (American Psychiatric Association, 2013) notes in its description of gender dysphoria that parents’ surprise at trans adolescents is common:
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. . . . Parents of natal adolescent females with the late-onset form also report surprise, as no signs of childhood gender dysphoria were evident.
Meanwhile, Littman’s study plays fast and loose with the very meaning of “rapid”, describing anything from one day to one year and effectively using the label of “rapid” merely to function as an invalidation (Pitts-Taylor, 2020):
Is a half-year wait for an appointment with a specialist far too quick? Or is it far too slow? The answer may hinge on whether the parent welcomes any gender affirmative treatment at all, or believes it is warranted in the first place. . . . These different durations are all deemed pathological, although the normative or “healthy” timeframe against which they are measured is not explicitly delineated. The study does not provide a stable referent for what constitutes pathological untimeliness. Rather, it treats a set of variegated durations as homogenously “rapid,” while applying the term to multiple objects, from subjects’ gender identifications to clinicians’ responses. Understood in semiotic terms, “rapid” is a floating signifier – it has a “semantic function whose role is to allow symbolic thought to operate despite the contradiction inherent in it” (Levi-Strauss, cited in Mehlman, 1972). The logic of ROGD uses (varied) patterns in the timing of (multiple) events to propose a singular etiological difference, social contagion, and to hypothesize the anomalous development of gender nonconforming youth.
We see what parents’ reports can tell us about their perception of their children’s gender identity development – and it really is only about their secondhand perceptions.
We can also choose to look at what Littman did not: the body of literature on the developmental course of transgender identity, gender dysphoria, and other gender-variant experiences among trans youth. As it turns out, trans people’s self-reports consistently and significantly differ from their parents in the description of their life course and gender development milestones. In several studies across decades, trans youth describe lengthy developmental timelines including landmarks of the first self-awareness of one’s gender variance, first identifying as transgender privately, first disclosing to someone else, first living as one’s gender part-time or full-time, and first pursuing medical transition. These events span years, not weeks.
Littman largely failed to engage with this literature:
- Grossman et al. (2005) found among 55 trans people aged 15-21, trans girls felt “different from others” at a mean of 7.6 years old, considered themselves transgender at 13.4 years, and first came out to anyone else at 14.2 years. Trans boys on average felt different at 7.5 years, identified as trans at 15.2, and first told someone at 17. For trans youth and young adults, this was a course of awareness and identity development lasting several years.
- Restar et al. (2019) found in 298 trans women aged 16-29, their average age of “initial self-awareness of transfeminine identity” was 9.9 years old, followed by “transfeminine expression in private” at an average of 12.9 years. They also first disclosed their trans identity to someone else at 15.8, presented as feminine in public at 17.4, and began taking feminizing hormone therapy at an average of 20.4 years old. Again, this process of identity development was not brief or passing, but lasted for a majority of their childhood.
- Kuper, Lindley, & Lopez (2019) found that in 224 trans youth aged 6-17, trans girls first self-identified as their gender at an average of 9.9 years old and first disclosed to their immediate family at 12.2 years. Trans boys similarly self-identified at 10.7 years old and disclosed to family at an age of 13.1 on average.
- Puckett et al. (2021) studied 415 Millennial trans people (born 1981-1996) and 196 Generation Z trans people (born 1997-2012). Millennials reported their gender first felt “different” at a mean age of 11.6 years, recognized themselves as having a transgender identity at 19, started living part-time as their gender at 20.8, lived full-time at 22.2, and accessed their first medical transition treatment at an average of 23.1 years old. Gen Z likewise experienced years of developmental milestones: feeling different at 11.5, identifying as trans at 15.2, living part-time at 16.1, full-time at 17 and medically transitioning at 17.6 years old on average.
Littman’s report of parental perceptions does not actually make any predictions as a hypothesis about a new and distinct syndrome, and it does not succeed in usefully paring down the space of possible observations of reality. These parental reports are fully compatible with a state of the world where trans youth’s gender dysphoria is not “rapid” in its onset at all.
The claims of ROGD are in danger of being unfalsifiable: Because trans youth consistently show this pattern of development and yet Littman’s methodology would never detect that pattern in favor of only reporting their parents’ subjective surprise, the supposed condition of ROGD can always serve as a possible reason to cast doubt on the authenticity of any trans person’s identity or experience of gender dysphoria. The youth who are clearly trans-identified and have been for many years could still be incorrectly classified as “rapid onset” by looking only at parental perspectives.
Based only on parental reports, are their children experiencing an inauthentic “rapid onset” gender dysphoria, or are they genuinely experiencing classic gender dysphoria as a trans person? How could you possibly tell the difference when working only from this limited evidence and misleading methodology?
This is a recipe for false negatives – a person with a trait is incorrectly identified as not having that trait. Wrongly declaring gender-dysphoric trans youth to be mistaken, non-dysphoric cis youth can then mean depriving them of the necessary affirming treatment for them to thrive in their authentic gender.
Parent reports of youth gender milestones are clearly not sufficiently accurate. And when we include both the parents’ perspectives and the reports of their trans youth on their gender identity development, that complete picture shows why this partial picture is so inaccurate. In June 2020 I made the following prediction about Littman’s study and the likely results of more comprehensive parent-child surveys:
Her results are nothing new, surprising, or inconsistent with previous findings; if she were to survey the trans children of her cis parent respondents, there is every reason to expect they would report the same lengthy trajectory of private identity development with discrete milestones occurring over many years.
Such a comprehensive survey has now been provided this year.