The Rapid Onset Gender Dysphoria Controversy

In August of 2018, a researcher from the Brown University School of Public Health published an article titled "Rapid-onset gender dysphoria in adolescents and young adults: A study of parental reports" in the highly respected journal PLoS One. The article suggested that there was a growing concern about young individuals assigned female at birth developing gender dysphoria suddenly, or quickly, during or after puberty. It also suggested that social media might play a role in the development of gender dysphoria in this population.

The publication of this article led to an almost immediate outcry from the community of gender diverse individuals and their family members as well as researchers in transgender health. There was a substantial concern that this article was scientifically unsound and motivated by anti-transgender beliefs. Over the next six months, criticisms of the article led to the journal initiating a formal review process that eventually led to the article being republished.

Its new title, "Parent reports of adolescents and young adults perceived to show signs of a rapid onset of gender dysphoria," was designed to emphasize that rapid-onset gender dysphoria was not an established diagnosis. Nonetheless, the controversy continued.

Rapid-Onset Gender Dysphoria

In the original article, the author Lisa Littman, MD, MPH at Brown University suggested that there was a growing concern about adolescent and young adults suddenly and rapidly developing gender dysphoria after having no symptoms of gender dysphoria during childhood.

The author also described parental reports of whole friendship groups suddenly becoming gender dysphoric and young people becoming gender dysphoric after compulsively watching videos and reading about gender identity on social media. She then defined rapid-onset gender dysphoria as "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."

Social Contagion

The author proposed that rapid-onset gender dysphoria could be the result of social and peer contagion. In other words, young people might present themselves as gender dysphoric because of exposure to gender dysphoric friends or gender dysphoric individuals in the media. Social and peer contagion are established constructs that have been associated with a number of mental health concerns and risky behaviors among adolescents. (A separate example of social contagion would be the way that young people are more likely to start smoking if they hang out with other peers who smoke.)

The author also suggested that the growth of social media channels run by individuals who were happier after a gender transition might suggest to youth with less specific behavioral health symptoms or general discontent that gender transition could be a way to solve those problems. As such, the goal of her paper was "to describe an atypical presentation of gender dysphoria occurring with sudden and rapid onset in adolescents and young adults; and to generate hypotheses about the condition, including the role of social and peer contagion in its development."

Coping Mechanism

The result of her paper was a suggestion that rapid-onset gender dysphoria was a "maladaptive coping mechanism" for adolescents and young adults assigned female at birth that might be a response to sexual and/or gender trauma as well as peer contagion. She likened it to anorexia as a way for young people to avoid feeling strong and negative emotions. The author also suggested that social media influences play an important role in teaching youth to mislead doctors and other adults about their gender, in order to get the treatment they want.

Because of her research, the author suggested that providers working with gender diverse youth should not rely on youth self-assessment of gender identity. Instead, they should prioritize parental and other providers' understanding of youths' gender development for two reasons. The first was that those adults might be more knowledgeable about the child's history than the children themselves. The second was that there was a substantial amount of information on the Internet teaching young people what to say, or even lie about, to get access to medical care for gender dysphoria.

The Conservative Media Response

A number of conservative news outlets hailed the publication of the rapid-onset gender dysphoria article for supporting parents who did not believe that their children were truly transgender and who were deeply concerned about a medical establishment that wished to help youth affirm their gender. Many articles published in conservative media placed the parents at the center of the story, hurt by children who abandoned them after their parents wouldn't support their gender identity. They also warned parents about the danger that their children might be made transgender if they spent time with transgender youth.

It can be incredibly difficult for parents to come to terms with a child's gender transition. One of the first things people learn about their babies is whether they are boys or girls, and parents tell themselves a story of who their children might be based on that information.

In fact, that is one of the biggest criticisms of the rapid-onset gender dysphoria article. Although it was portrayed as research about adolescent gender identity, it would be more accurately described as research about parental perceptions.

Lack of Understanding

One of the biggest criticisms of the study was that it failed to look at other possible explanations for the observations parents had made. For example, youth are known to hide their gender questioning from their parents when they are concerned their parents will be upset, judgmental, or simply not understand. Many gender diverse youth actively seek out other gender diverse youth as friends or supports. Youth, particularly those who do not feel like their parents will accept their gender diversity, seek out information online and from their peers.

When gender dysphoria becomes overwhelming, youth may approach their parents to seek care in a way that seems sudden, from the parents' perspective, but has actually been a process that has taken place over a number of years.

In short, most of the observations about adolescent gendered behavior that were described in the paper could be just as easily explained by a disengagement in the parent-child relationship as by a rapid onset of gender dysphoria.

The Professional Response

WPATH

The World Professional Association of Transgender Health (WPATH) is an international body that sets standards of care for transgender medicine. Although the organization is not without its detractors, it is generally considered as a primary source for evidence-based practices in transgender medicine. The WPATH Standards of Care are widely used for the development of insurance coverage guidelines and medical practice policies.

Approximately one month after the publication of the original article, WPATH published a position paper stating significant concerns about the proposed diagnosis of rapid onset gender dysphoria.

It opened with the following paragraph:

"The World Professional Association for Transgender Health Board of Directors reaffirms the deliberative processes by which diagnostic entities and clinical phenomena are classified and established. These academic processes reside within the respective professional medical organizations and are led by workgroups formed by expert scientists, clinicians, and stakeholders, often over long periods of time, with high levels of scientific scrutiny of the evidence-based literature."

The statement continues to acknowledge the term rapid onset gender dysphoria.

"Therefore, it constitutes nothing more than an acronym created to describe a proposed clinical phenomenon that may or may not warrant further peer-reviewed scientific investigation."

The statement acknowledged the importance of research in understanding the development of gender identity in adolescents. However, it also cautioned against any term used "to instill fear about the possibility that an adolescent may or may not be transgender with the a priori goal of limiting consideration of all appropriate treatment options."

Expert Opinion

Other scientists also expressed their concerns about the initial publication. In the middle of 2019, a methodological critique of the article was published in the Archives of Sexual Behavior by another researcher from Brown University. The researcher identified many of the same concerns as the community. She also brought up several more specific concerns including the fact that the Littman study was framed in a way that was inherently pathologizing to gender diverse individuals.

In addition, this researcher noted that the consent documents opened with statements about how the study was looking at social and peer contagion. As such, it was more likely to attract participants who believed in these concepts. It also may have set expectations that information about such associations are what was being sought. She goes on to note about the Littman paper:

• Neither rapid onset gender dysphoria nor puberty were clearly defined in the questions about when and if the proposed disorder occurred.
• Asking parents to diagnose children using DSM criteria is inappropriate, particularly based on distant memory.
• Much of the recruitment was from websites that are aimed at parents who reject the notion that their children could be transgender.
• The survey questions were phrased in a biased manner.
• The selection of which questions were analyzed may have introduced bias into the description of the results.

The Rapid-Onset Gender Dysphoria Correction

Even before the article analyzing the methodology of the original rapid-onset gender dysphoria paper was published, PLoS One had decided to reassess the article. They then decided to re-publish it, as is described below.

"After publication of this article, questions were raised that prompted the journal to conduct a post-publication reassessment of the article, involving senior members of the journal’s editorial team, two Academic Editors, a statistics reviewer, and an external expert reviewer. The post-publication review identified issues that needed to be addressed to ensure the article meets PLoS One’s publication criteria. Given the nature of the issues in this case, the PLoS One Editors decided to republish the article, replacing the original version of record with a revised version in which the author has updated the Title, Abstract, Introduction, Discussion, and Conclusion sections, to address the concerns raised in the editorial reassessment."

It also acknowledged some of the limitations of the study. Unfortunately, it failed to address a number of others.

Probable, Problematic, or Both?

Rapid onset gender dysphoria is not a diagnosis. If anything, it is a research hypothesis. The question of whether it is one that should be explored is ongoing. Clinicians who work with gender diverse youth are deeply disturbed by the original article, and rightly so. Clinicians of this kind are accustomed to working with adolescents who have often been traumatized by adults who refuse to believe them when they say who they are.

Important Questions Raised

That said, the article does raise some interesting questions that should and could be examined in a way that does not inherently pathologize gender identity.

For example, the number of non-binary youth who were assigned female at birth seems to be growing quite quickly. Why is this? It could be that the visibility of non-binary individuals allows other people to recognize the truth about themselves. It could be a deep discomfort with misogyny in modern society that leads to girls not wanting to be perceived by the world as girls. It could be something else entirely.

Are there members of youth who "try on" a gender diverse identity because the peers they are closest to are gender diverse? If so, is there anything wrong with that? Transgender teens are often encouraged to try to be cisgender. Lesbian and gay teens are often encouraged to try to be straight. Could gender exploration be a healthy part of self-development?

Is it common for adolescents to mislead providers to convince them of their gender identity? If so, why? What signs are clinicians looking for to determine the truth? What are legitimate criteria for determining the truth in these cases?

A Word From Verywell

When doing research in transgender health and gender diversity, it is important to pay attention to context. It is important to be aware of the stigma faced by transgender people and how that can affect their care. It is important to be upfront about biases, and how they may affect the outcomes of the research. Had the original article on rapid-onset gender dysphoria been framed more accurately as a study of parent perceptions, it could have led to some interesting discussion on the potential role of social networks in gender cognition.

It might have stimulated research describing differences in parent and child perceptions of a child's gender journey. Unfortunately, even its revised state, the level of associated controversy may be sufficient to stifle debate.