On "Rapid Onset Gender Dysphoria"

About a year or so ago, we started hearing about "Rapid Onset Gender Dysphoria".  This has primarily been a result of a "poster study abstract" by Lisa Littman.  For the most part, the supposed phenomenon has been commented on at length by TERF blogs like "Fourth Wave Now", and "Transgender Trend" (no links provided - I'm not going to send traffic to those sites).

Now we have the full paper by Dr. Lisa Littman available on PLOSone: Rapid-onset gender dysphoria in adolescents and young adults: A study of parental reports.

This is a deeply flawed study that needs to be examined carefully.  What follows is inevitably going to be a lengthy post.  If you don't want to read all the gory details, skip to Conclusions.

[Warning:  The paper is lengthy, so my analysis is going to be quite lengthy as well.  Unlike material published on opinion websites like "The Federalist", this paper is written by a sophisticated writer, and identifying the problems with it is more complex, please bear with me].

This post is quite lengthy, so I am putting my summary here, and readers interested in a more in-depth examination of the paper are welcome to explore further.  

Conclusions

Overall, this is a deeply flawed study.  It suffers from both bias and methodological errors. Although the focus of the study is ostensibly to examine the parents' experiences of their adolescent and teenage children declaring their transgender identity, the author ends up turning it into an assessment of the children themselves.  While understanding how parents of transgender youth perceive their child's declaration of their identity is a worthy domain, using said same perceptions to indirectly diagnose (or invalidate) the declared identity of the children is both ethically suspect as well as poor scholarship.  

Methodologically, this study is doomed from the start by three major factors. First, the sampling method chosen was all but guaranteed to produce a very limited sampling of parental experiences.  Second, the questionnaire can be accused of being both misleading in the wording of the questions and the order of those questions.  Thirdly, it starts from the implicit assumption that the construct of "Rapid Onset Gender Dysphoria" is a valid construct.  This assumption has in no way been adequately explored or proven in this study or any other study that this writer is aware of. 

Lastly, there are a number of places in the article where the author engages in implying that the broader transgender community is engaging in what amounts to recruiting. These kinds of accusations have been used to justify oppressing the LGBT community in the past. They are neither new, nor particularly surprising in this light. Again, Dr. Littman could have lent her study a degree of credibility simply by avoiding implying such accusations.

While Dr. Littman's study could have been a valuable and insightful examination of parental response to their child's declaration of being transgender, she decided to take a twist and instead of evaluating parental responses she chose to try and evaluate the "validity" of the children's declarations instead.  In doing so, Dr. Littman rendered this particular study irrelevant to furthering the understanding of transgender youth or their parents. 

Issues

Sample Acquisition

Right off the top, we have a significant issue with this study - namely the way that the researcher(s) went about acquiring their sample data:

Recruitment information with a link to the survey was placed on three websites where parents and professionals had been observed to describe rapid onset of gender dysphoria (4thwavenow, transgender trend, and youthtranscriticalprofessionals).

That's right - our researcher went to 3 websites, all of which are well known anti-trans, or Trans Exclusionary Radical Feminist (TERF) controlled.  These blogs are all known for their propensity to publish inflammatory, and misleading, articles about transgender youth and how they are treated.  In general, these blogs tend to be alarmist and deceptive. This pretty much guarantees a significant degree of bias in the sample data.

A modest, but likely ineffectual, attempt to mitigate this was made by asking people to "spread the link to the survey" to people and communities that would find it of interest. While laudable, we have to recognize that the majority of readers of these websites are already biased against transgender people in general, and are likely to spread such information to other like-minded communities.  It would be interesting to know if the links were shared through Reddit, 4chan, or 8chan, and which sub communities in those forums became involved.

The Survey

The survey itself is a jumbled mess.  There are some questions which would legitimately elicit reasonable information, and there are others where the design of the question and associated response sets read like the study's author spent a lot of time reading alarmist literature about youthful gender transitions. 

There is a problem with this question that we need to address.  First, this presupposes that a "gender therapist" doesn't deal with issues in a person's life beyond Gender Dysphoria.  The reality is that you cannot effectively treat gender dysphoria without actively engaging with, and addressing some of the other issues in your client's sphere.  

These two questions are good examples of what I will call "leading" questions.  First, the response sets for the first question is loaded with phrases which are clearly going to provoke anxiety on the part of the respondent.  Second, the order of the questions is such that some of the weighted wording will prime the respondent to provide worst-case (or perhaps better described as "scariest case") responses to subsequent questions.  

There are many reasons a child might use online resources to help them prepare for something like disclosing that they are transgender.  Heck, even adults who are coming out for the first time will do this.  However, as we shall see later on, this becomes a key part of the analysis that the author makes. Suffice it to say that these kinds of questions are in fact not only "leading" the respondent towards particular kinds of responses, but they also are structured in such a way as to suggest things to the respondent which may or may not be objectively true.  

This survey instrument is both misleading and poorly structured.  It isn't difficult from examining a subset of the questions to guess what kinds of responses the authors are seeking.  This combines with the sampling strategy used to produce a set of data that is going to be deeply flawed. 

Analysis

The analysis is interesting both because it carries a twist in the direction of the analysis that we should pay close attention to.  

It is important to note that none of the AYAs described in this study would have met diagnostic criteria for gender dysphoria in childhood (Table 3). In fact, the vast majority (80.4%) had zero indicators from the DSM-5 diagnostic criteria for childhood gender dysphoria with 12.2% possessing one indicator, 3.5% with two indicators, and 2.4% with three indicators.

Here, we have the study's author making broad diagnostic claims about the children of the people who responded to the online survey.  This is a second-hand diagnosis at best, and one which is profoundly flawed.  What we really have is the parents saying that their children wouldn't meet the diagnostic criteria.

I would like to bring to everyone's attention the following statement from the 7th Edition of the WPATH Standards of Care For Transgender and Gender Non-Conforming Individuals:

Data from one study suggest that more extreme gender nonconformity in childhood is associated with persistence of gender dysphoria into late adolescence and early adulthood (Wallien & Cohen- Kettenis, 2008). Yet many adolescents and adults presenting with gender dysphoria do not report a history of childhood gender nonconforming behaviors (Docter, 1988; Landén, Wålinder, & Lundström, 1998). Therefore, it may come as a surprise to others (parents, other family members, friends, and community members) when a youth’s gender dysphoria first becomes evident in adolescence.

We should understand something here.  Children are very much experts in their own families and the attitudes of those families.  A child who is aware - directly or indirectly - that their parents are hostile to LGBTQ people is going to become amazingly talented at hiding their inner feelings. I think this is incredibly important to recognize, because at no point do we have any evidence that the researcher attempted to acquire the stories of the very children that she is claiming to analyze.

The AYAs who were the focus of this study had many comorbidities and vulnerabilities predating the onset of their gender dysphoria, including psychiatric disorders, neurodevelopmental disabilites, trauma, non-suicidal self-injury (NSSI), and difficulties coping with strong or negative emotions (Table 4).

While it is important to understand other mental health conditions and understand how they might affect a particular case, there are few mental health diagnoses which can be seen as contraindications for treating gender dysphoria.  While any mental health professional should be aware of, and prepared to help a client address other aspects of their mental health, diagnoses such as anxiety or depression certainly are not contraindications, neither would someone being autistic.

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. The most striking examples of “not seeming at all gender dysphoric” prior to making the announcement included a daughter who loved summers and seemed to love how she looked in a bikini, another daughter who happily wore bikinis and makeup, and another daughter who previously said, “I love my body!”

I want to bring to your attention how this paragraph underscores a key criticism of this paper.  The construct of "Rapid Onset Gender Dysphoria" is entirely defined not by the experiences of transgender youth, but by the experiences of their parents.  This is significant, because as a diagnostic lens it is profoundly flawed.  You cannot assess a person's experience through another person's experience of their story.  It simply does not make sense to attempt to do so.

Perhaps just as destructive to the credibility of this paper is the examples drawn from the responses.  These are clearly chosen for their shock value. Yet, they tell us little about the specific cases, and the context of the children. In short, they appear to be largely designed to enable the reader to assume that adolescent-onset gender dysphoria is somehow not valid.

I want to be very clear about something with these "case summaries":  They are clearly based on what the parents have observed, and are therefore third party assessments.  The second point is that the author clearly thinks that the parents know better than the child themselves.  This sets up the entire construct being investigated as a means to invalidate the child's expressed identity.

The majority (76.5%) of the surveyed parents felt that their child was incorrect in their belief of being transgender

Here is the fundamental problem with the entire article in one sentence. While parents may have insight into their children, when exploring a construct like ROGD, a lack of insight on the part of the parents is not indicative of anything except the parents' experience.  The fact that the author does not mention this rather obvious confounding factor in their study leaves them open to accusations of bias.

Parents described intense group dynamics where friend groups praised and supported people who were transgender-identified and ridiculed and maligned non-transgender people. Where popularity status and activities were known, 60.7% of the AYAs experienced an increased popularity within their friend group when they announced a transgender-identification and 60.0% of the friend groups were known to mock people who were not transgender or LGBTIA (lesbian, gay, bisexual, transgender, intersex, or asexual).  

Again, we have to bear in mind that these are the experiences of the parents, not those of the youth.  So, a more correct set of statements would be that the "parents perceived group dynamics as intense". What the youths involved experienced is far from being so clear. Further, the underlying question itself is problematic simply because of the context in which it occurs in the questionnaire.  The surrounding questions are all focused on the idea of identifying potential "social contagion".  No questions about social adaptation are nearby, and the subsequent questions clearly are written in the vein of establishing whether the child became part of a peer pressure group.  This identifies yet another issue with the fundamental assumptions in this paper.

Qualitative Analysis

Up to this point, the author has focused on the most readily quantified aspects of the survey.  Now she shifts to trying to summarize the "additional information" that the respondents have provided.  Rather than go through the specific instances and discuss them in detail, I'm just going to point out how the qualitative material really reflects the underlying response bias issue that I mentioned earlier.  

One participant explained, “They are constantly putting down straight, white people for being privileged, dumb and boring.” Another participant elaborated, “In general, cis-gendered people are considered evil and unsupportive, regardless of their actual views on the topic. To be heterosexual, comfortable with the gender you were assigned at birth, and non-minority places you in the ‘most evil’ of categories with this group of friends. Statement of opinions by the evil cis-gendered population are consider phobic and discriminatory and are generally discounted as unenlightened.”

Seriously, this reflects a significant problem with the data sample used.  The websites that the author used to promote this study are well known for a substantial anti-transgender bias.  It is notable that these kinds of themes appear throughout the qualitative analysis, and the author never presents non-distressing examples.  This suggests either that the author did not receive any reasonable responses from parents (indicating a significant amount of data set bias), or she chose to ignore such responses because they were "uninteresting" (reflecting author bias).

Hypotheses

The next area of concern in this paper is in the hypotheses that the author derives based on their analysis.

Hypothesis 1: Social contagion is a key determinant of rapid-onset gender dysphoria (ROGD).
Hypothesis 2: ROGD is a maladaptive coping mechanism for AYAs.

I take exception to both of these hypotheses for several reasons. First, the author is presupposing the validity of the construct “Rapid Onset Gender Dysphoria”, without citing any pre-existing research which establishes the existence of such a condition.  Second, the first hypothesis assumes the existence of a “social contagion” effect with respect to the construct of gender dysphoria.  The idea of “social contagion” is deeply suspect, and should be treated with skepticism.  Thirdly, the second hypothesis implies gender dysphoria is “maladaptive”, without exploring what exactly it is that the patient would be adapting from/to that would make this "maladaptive".

The second dimension of these hypotheses that is deeply concerning is the fact that the author is apparently setting up to draw conclusions about transgender youth based not upon the experiences of those youth, but on the indirect experience of their parents. This is very concerning.

Assuming ROGD is even a valid construct clinically is deeply suspect at this point in time.  I think the author would have been much better off working with the concept of Adolescent Onset as is more common in the research literature.  

Peer Contagion

Peer contagion has been shown to be a factor in several aspects of eating disorders. There are examples in the eating disorder and anorexia nervosa literature of how both internalizing symptoms and behaviors have been shared and spread via peer influences [28–32] which may have relevance to considerations of rapid-onset gender dysphoria. Friendship cliques can set the norms for preoccupation with one’s body, one’s body image, and techniques for weight loss, and can predict an individual’s body image concerns and eating behaviors [28–30].

There is an enormous problem with attempting to link across conditions, as the author is doing here.  We have no explicit evidence which substantiates any clinical similarity between Gender Dysphoria and Eating Disorders.  To presuppose the existence of such a similarity as part of a hypothesis renders the hypothesis increasingly speculative, weakening the clarity of any findings.

While the concept of peer contagion (better known to the old fossils like your writer as "peer pressure"), has a certain validity as a question which therapists should explore when evaluating youth for further transition related interventions.  However, without supporting evidence that such a construct is at play in adolescent-onset Gender Dysphoria, this is little more than a poorly constructed attempt to claim that transgender youth are lying.

The pro-eating disorder sites provide motivation for extreme weight loss (sometimes calling the motivational content “thinspiration”). Such sites promote validation of eating disorder as an identity, and offer “tips and tricks” for weight loss and for deceiving parents and doctors so that individuals may continue their weight-loss activities [33–35]. If similar mechanisms are at work in the context of gender dysphoria, this greatly complicates the evaluation and treatment of impacted AYAs.

There's a problem here.  The author has embedded a secondary hypothesis in the middle of their analysis of the concept of "social contagion".  Demonstrating this hypothesis alone is a significant research effort, and well beyond the apparent scope of this paper.

In the past decade, there has been an increase in visibility, social media, and user-generated online content about transgender issues and transition [36], which may act as a double-edged sword. 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.

This particular paragraph is very concerning, because it sets out the foundation for the recycling of a common attack levelled at LGBTQ people over decades - the idea that this population "recruits" from youth. Such attacks have long been a staple of those who would have the entire LGBTQ community "return to the closet".  Unfortunately, these attacks are also pernicious because they require the community to prove a negative - which is almost impossible to do.

References

Littman L (2018) Rapid-onset gender dysphoria in adolescents and young adults: A study of parental reports. PLoS ONE 13(8): e0202330. https://doi.org/10.1371/journal. pone.0202330

Coleman, E., Bockting, W., & Botzer, M. (2011). 7th Version of WPATH Standards of Care. International Journal of Transgenderism, 13, 165-232.