Roberto D’Angelo Psy.D., M.B.B.S., FRANZCP, M.Med.(Psychotherapy)
Lisa Marchiano LCSW, NCPsyA
Lisa Littman’s peer-reviewed paper can be downloaded from the academic journal PLOS ONE at http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0202330
Julia Serano’s critique is available on the online publishing platform Medium at https://medium.com/@juliaserano/everything-you-need-to-know-about-rapid-onset-gender-dysphoria-1940b8afdeba
Lisa Littman is a physician and researcher in the Department of Behavioral and Social Sciences at the Brown University School of Public Health. Her groundbreaking publication examining the proposed phenomenon of Rapid Onset Gender Dysphoria has been aggressively criticised by trans activists. Activists argue that Littman’s paper and the actual notion of ROGD, are transphobic. We find this response perplexing. Littman is attempting to examine the possibility that some young people who come to believe they are trans may be doing so for complicated reasons, and that transitioning may not always be an appropriate treatment in these cases. This does not in any way imply that trans identity is not legitimate. The paper focuses on a particular subgroup of people identifying as trans and is not a reflection of trans experience in general and therefore cannot be generalized to apply to all trans people.
We believe that Littman’s paper is fundamentally supportive of the trans community. If Littman has correctly identified a subgroup of people identifying as trans, this will contribute to ensuring that those individuals who will actually benefit from transitioning receive the appropriate support. It will also help identify a group of individuals who have serious mental health needs that would be bypassed or missed if their trans claims were not understood in the complex light that Littman is exploring. The trans community lobbies powerfully for the human rights of those who are gender diverse. Littman’s paper is entirely consistent with these aims in that it raises questions about how the human rights, including the right to appropriate mental health care, of a subgroup of trans youth can be met.
The following address the specific criticisms Serano raises in her article:
This was not a study of the children themselves, but rather their parents
This was indeed a study of the children, however, the children themselves were not directly interviewed or assessed. Their parents were the sources of information about the onset of gender dysphoria in their children. Serano claims this aspect of the study invalidates its findings. It is standard practice in child and adolescent psychiatry to obtain full histories from parents, who provide information essential to accurate diagnosis. Parents are in fact frequently given questionnaires and standardized rating scales to complete which are used to clarify the diagnosis. Gathering data from parents is a legitimate part of child and adolescent mental health diagnosis and care.
Parents were sourced from sites which are allegedly anti-trans and which invented and promote the idea of ROGD
These websites (4thwavenow.com, transgendertrend.com, youthtranscriticalprofessionals.org) and the parents who frequent them did not invent the term ROGD. It was proposed by Littman herself. The first appearance of the term rapid-onset gender dysphoria was in the recruitment information for Littman’s study that was posted on these websites in the summer of 2016. The term seemed to resonate with the parents and it has become more widely used since that time.
Serano argues that this was a methodological flaw, as it involved asking these parents questions that already assume the legitimacy of ROGD as a phenomenon, in effect allowing Littman to obtain the answers she wanted to find. It is, in fact, standard practice to contact groups, services or websites which might provide access to the subjects you believe will be relevant to your study. Many of the frequently quoted studies of trans populations utilized trans-affirmative support groups and websites to find study subjects, and so Serano’s argument would imply that these studies suffer from the same flaw or bias.
Further, Littman undertook an observational, qualitative study to examine what parents on these sites were reporting as ROGD. The abstract of Littman’s study states “The purpose of this study was to document and explore these observations and describe the resulting presentation of gender dysphoria, which is inconsistent with existing research literature.” The intention was to document this phenomenon as reported by parents and this is exactly what her paper reports. The sampling method she used is a legitimate methodology that is consistent with the purpose of the study. She concludes that ROGD appears to represent a distinct entity and that more research is needed. It would be unreasonable to conclude that the study provides irrefutable proof that ROGD is a distinct entity, and Littman does not make this claim anywhere in the report.
Is this really a new phenomenon?
Serano claims that adolescent onset dysphoria is nothing new. In fact, it has long been acknowledged that some natal males will experience gender dysphoria that first appears during adolescence. However, until very recently, adolescent onset gender dysphoria in natal females was almost unheard of. Now, this group often makes up the majority of those presenting for services – about 70% at the Tavistock Gender Identity Development Service in London, for example.
The study was published in PLOS One rather than a “more respectable journal”
It is not clear how Serano comes to the conclusion that PLOS ONE is not a respectable journal. The PLOS ONE website states that its mission is to publish “scientifically rigorous research”. It goes on to state that “Each submission to PLOS ONE passes through a rigorous quality control and peer-review evaluation process before receiving a decision”. PLOS ONE has published many highly regarded papers, including the seminal 2011 gender reassignment follow-up study by Dhejne et. al. from the Karolinska Institute. PLOS ONE has published many papers which have made important contributions to the still-evolving understandings of gender dysphoria and transgender experience.
PLOS ONE states that they differ from other journals in that their decision to publish is based solely on the scientific rigor of the paper, rather than the “subjective judgment” of the editors. In the current political climate, perspectives which question the dominant understanding of trans frequently evoke intense controversy and protest, at its most extreme resulting in the “no-platforming” of individuals. It is likely that another journal may have felt Littman’s findings would attract too much negative publicity to their journal to publish it. PLOS One is to be applauded for its transparent publishing policy and bravery.
How would a researcher prove that a novel form of gender dysphoria exists?
Littman concludes her study as follows: “More research is needed to better understand rapid-onset gender dysphoria, its implications, and scope”. The questions Serano raises to invalidate Littman’s study are in fact the very questions that Littman would probably wish to see investigated in the additional research she is recommending. Serano argues that for ROGD to be established as a new diagnosis that differs from gender dysphoria, we need to: show “that there is some specific reproducible cause of gender dysphoria in “ROGD kids” that is largely or completely absent from kids who experience regular old gender dysphoria”; or to show “that kids who are deemed ROGD exhibit an entirely different spectrum of outcomes than other transgender children”; or to “distinguish between“ROGD kids” and the children described in the aforementioned DSM-5 and WPATH Standards of Care” . These are excellent questions that would indeed help us better understand ROGD. It is possible that medical transition may be the right treatment and lead to the best outcome for some gender dysphoric youth but not for others. Any research that deepens our understanding about who might potentially benefit most from which treatments ought to be welcomed.
There are many different transgender trajectories and transgender identities
Serano argues that Littman is attempting to create a new category of Gender Dysphoria and that this harkens back to previous categorizations of Gender Dysphoria (such as those proposed by Blanchard and Bailey). Serano further argues that the field has moved on from these categorizations and that “trans people vary from one another in almost every possible way”. Serano’s criticism does not hold as Littman is, in fact, attempting to illuminate yet another way that people might come to identify as trans, in fact adding to the great variety of possible trans trajectories that Serano claims. And even within the purported new category of ROGD, Littman’s own data illustrates how much individual variation there is in the trajectories of the subjects in her study. Serano and Littman seem to be in agreement here.
Correlation does not imply causation
Littman found a high proportion of the young people in her study had a number of friends in their friendship group who were trans-identified and that the majority had experienced an increase in their usage of the internet and social media prior to announcing that they were trans. Serano argues that the correlation between these factors and the self-identification of young people identifying as trans does not mean that it caused their trans identification. This is correct. Correlations such as these, however, warrant further investigation to determine whether there is, in fact, a causative link. This is in fact how the aetiologies of many conditions have been discovered, leading to the development of effective prevention strategies or treatments.
Littman’s findings in this area raise the possibility of social contagion in relation to ROGD, a notion which Serano argues strongly against. Whilst Serano’s arguments are plausible, it is also plausible that social contagion is a factor in some cases of trans, particularly as it has been associated with numerous other social phenomena. They include mental health issues such as suicide and deliberate self-harm and it also appears that more complex behaviors such as obesity, bulimia, and other eating disorders can spread by social contagion. Whilst Littman’s data does not prove that social contagion is operative (and she makes no claims of this kind), her qualitative research design did elicit information that is highly suggestive, particularly that the young people were using language that was scripted or wooden and that parents believed had been copied verbatim from online sources.
The operation of social contagion in relation to adolescent gender dysphoria is a possible explanation for the dramatic change in the demographics of young people presenting to gender clinics. Serano claims there are no reliable statistics confirming that there has been an increase in the numbers of natal female adolescents seeking treatment. This is incorrect. This has been reported by the Center of Expertise on Gender Dysphoria at the VU Hospital in Amsterdam and similar data is also available from Tavistock Gender Identity Development Service.
Serano’s important omission
As we have already stated, we believe there is an important human rights issue at stake here in relation to young people receiving appropriate mental health care. This includes developing our understanding of which young people will benefit from transitioning and which young people require other forms of intervention other than gender-affirming care to address their difficulties. We fundamentally disagree with Serano’s implicit critique that Littman’s paper is transphobic. We believe Littman’s paper is supportive of all youth, including trans youth because it attempts to expand our awareness of the diversity and complexity of youth mental health needs.
For example, Littman found that 62.5% of young people were diagnosed with one or more psychiatric disorder prior to announcing that they were trans. 48.4% had experienced stress or trauma. 45% were engaging in self-harm prior to coming out as trans and 58% had difficulties with emotion regulation. These proportions appear very high and suggest a troubled, clinical population. And concerningly, of those parents who were aware of the content of their child’s consultation with a mental health professional 71.6% reported that the clinician did not explore mental health issues, previous trauma or other potential causes for gender dysphoria. Littman reports: “The very high expectation that the majority of AYAs held that transition would solve their problems coupled with the sizable minority who became unwilling to work on their basic mental health issues before seeking treatment support the concept that the drive to transition might be used to avoid dealing with mental health issues and aversive emotions.”
Littman’s study corroborates what other clinicians around the world have been noting in recent years. For example, the Report of the American Psychiatric Association Task Force on Treatment of Gender Identity Disorder notes the following:
“In the Toronto sample, there is significant psychopathology in the adolescent sample, particularly in the late-onset group. As indicated above, many of these adolescents also present with a shorter duration of cross-gender feelings and less clarity or consistency regarding the nature of their gender concerns as well as histories of trauma, psychosis, body dysmorphic disorder, and severe depression that seem related to their cross-gender feelings. Despite these observations, often these adolescents are very certain that SRS is the “only” solution to their dilemmas and because of this may become very pressuring of doctors in their quest for SRS. Access to internet sites that uncritically support their wishes appears to facilitate their intense desire for hormones and surgery”
Serano fails to take into account what is well-known about adolescent identity development and cognitive development. We generally understand adolescence to be a time of identity exploration in which young people may try on various ways or being in the world. While such exploration is healthy, making permanent medical decisions on the basis of this exploration is not usually considered to be a good idea. In the United States, adolescents are generally not allowed to use tanning beds or get a tattoo under the age of 18 without parental permission. This is because we recognize that adolescents are not good at evaluating risks until they reach full cognitive maturity around the age of 25. It is the responsibility of the medical and therapeutic establishment to guard against both under-diagnosis and treatment, as well as over-diagnosis and treatment, either of which can be harmful. Gender dysphoria ought not to be any different simply because it is more politicized.