Rapid Onset Gender Dysphoria Controversy

Rapid onset gender dysphoria (ROGD) is a controversial neologism which describes an alleged socially mediated subtype of gender dysphoria. Brown University School of Public Health assistant professor Lisa Littman created the term to describe surveyed parents' accounts of their teenage children suddenly manifesting symptoms of gender dysphoria and self-identifying as transgender simultaneously with other children in their peer group. Littman speculated that rapid onset of gender dysphoria could be a "social coping mechanism" for other disorders. ROGD is not recognized by any major professional association, with Littman noting that it is "not a formal mental health diagnosis at this time".

Littman published a descriptive study in PLOS One in August 2018. Criticism was voiced by transgender activists, and two weeks after publication, PLOS One responded by announcing a post-publication review of the paper. In March 2019, the journal concluded its review and republished Littman's revised and corrected version.

On the same day as PLOS One announced its post-publication review, Brown University retracted its press release promoting the study. The controversy grew as articles and opinion pieces, both critical and supportive, were published in mainstream media discussing concerns about the study's methodology and the validity of its hypotheses, as well as issues of academic freedom. Subsequently, other studies remarked on a much increased incidence of youth seeking care for dysphoria.

Publication

Lisa Littman, an American physician and researcher, coined the term "rapid-onset gender dysphoria" at the outset of her research for a descriptive study originally titled "Rapid-onset gender dysphoria in adolescents and young adults: A study of parental reports". Littman's medical specialties are in preventive medicine and public health, as well as obstetrics and gynecology. Her research interests relate to reproductive health, gender dysphoria, detransition, and maternal and child health including prematurity and the use of substances in pregnancy. Littman joined the faculty of the Brown University School of Public Health in 2018 as Assistant Professor of the Practice in Behavioral and Social Sciences.

Littman became interested in the possible role of "social contagion" in gender dysphoria among young people, and conducted a study by surveying around 250 parents recruited from three websites where she had seen parents describe sudden gender transitions in their adolescents. She presented preliminary results at a 2017 conference, and a descriptive study was initially published in PLOS One in August 2018.

Littman's study described cases of a rapid onset of gender dysphoria based on reports by the surveyed parents, along with information that was collected about the children's peer group dynamics, social media use, and prior mental health issues. Littman speculated that rapid onset of gender dysphoria could be a "social coping mechanism" for other disorders, such as depression and anxiety caused by adolescent trauma.

According to coverage in the news section of Science, the study found that "among the young people reported on—83% of whom were designated female at birth—more than one-third had friendship groups in which 50% or more of the youths began to identify as transgender in a similar time frame", which the Science coverage described as probably "the most explosive of Littman's findings".

Correction

The paper was met with a strongly negative reaction from transgender activists who stated that it had already been politicized, and that there was self-selection bias of the subjects that Littman surveyed, as she only surveyed the parents and not the young people themselves nor the health professionals caring for them. Responding to negative comments, PLOS One announced two weeks after publication that it would open a post-publication review of the study's methodologies and analyses.

In March 2019, PLOS One completed its post-publication review, and Littman's corrected version of the paper was published on March 19, 2019. In the journal's blog, PLOS One editor Joerg Heber apologized "to the trans and gender variant community" for the previous review and publication, saying "the study, including its goals, methodology, and conclusions, were not adequately framed in the published version, and that these needed to be corrected." Heber noted that the hypothesized condition of ROGD had "not yet been clinically validated."

In a notice of correction prefacing her updated version of the study, Littman stated:

[T]he 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. The Materials and methods section was updated to include new information and more detailed descriptions about recruitment sites and to remove two figures due to copyright restrictions. Other than the addition of a few missing values in Table 13, the Results section is unchanged in the updated version of the article.

PLOS One's editor wrote that "the corrected article now provides a better context of the work, as a report of parental observations, but not a clinically validated phenomenon or a diagnostic guideline". On behalf of the journal, Heber wrote, "Correcting the scientific record in this manner and in such circumstances is a sign of responsible publishing", where further scrutiny was called for to "clarify whether the conclusions presented are indeed backed up by the analysis and data of that original study." Heber later stated, "At its core, the survey of the parents stands as it is... We let the original results stand."

Terminology

The term "rapid onset gender dysphoria", coined by Littman, first appeared in a July 2016 notice that was posted on four websites, recruiting parents to respond to a research survey that Littman described as "Rapid onset gender dysphoria, social media, and peer groups". In the title of Littman's poster abstract for the study, published in February 2017, the phrase appeared as "Rapid Onset of Gender Dysphoria".

According to Littman, "Rapid-onset gender dysphoria (ROGD) is not a formal mental health diagnosis at this time." She wrote:

This study of parent observations and interpretations serves to develop the hypotheses that rapid-onset gender dysphoria is a phenomenon and that social influences, parent-child conflict, and maladaptive coping mechanisms may be contributing factors for some individuals. ... This report did not collect data from the adolescents and young adults (AYAs) or clinicians and therefore does not validate the phenomenon.

In a formal comment published by PLOS One at the conclusion of its review, Angelo Brandelli Costa wrote, "The level of evidence produced by the Dr. Littman's study cannot generate a new diagnostic criterion relative to the time of presentation of the demands of medical and social gender affirmation." Costa suggested, "Several procedures still need to be adopted to generate a potential new subcategory of gender dysphoria that has not yet been clinically validated. One of these procedures is the assessment of mental health professionals trained according to the World Professional Association for Transgender Health (WPATH) and the American Psychological Association (APA) guidelines, interviewing not just the family, but the youth (longitudinally)."

Reactions

The 2018 publication of the paper led to controversies that included criticism and defenses of the study's methodology by scientists, social activist groups and by professional organizations. Disputes also arose among socially conservative and liberal opinion writers about academic censorship.

Institutional

On the same day that PLOS One announced its review, Brown University took down a press release they had earlier posted about the paper. Responding to critics, Brown University President Christina Paxson and Provost Richard Locke said they had not infringed on academic freedom and stated that Brown's commitment to only "publicize research that unassailably meets the highest standards of excellence" required Brown to retract the press release after PLOS One opened an investigation on the paper in question. They said that "given the concerns raised about research design and methods, the most responsible course of action was to stop publicizing the work published in this particular instance. We would have done this regardless of the topic of the article."

Social and political commentary

The reactions to Brown's removal of the press release from their website included criticism by a former dean of Harvard Medical School.

Aside from questions about the scientific validity of the condition, the political implications of the alleged condition were a source of heated discussion. Critiques of sociological aspects of the study have been published in peer-reviewed journals. The hypothesized condition was called "a poisonous lie used to discredit trans people" in the op-ed section of The Guardian, while it was called an explanation for the experiences of multiple parents in the op-ed section of the Wall Street Journal. Publications such as The Conversation and Slate condemned what they saw as politicization of science by social conservatives, while Madeleine Kearns, a contributing writer at National Review, described the alleged condition as "particularly concerning" and called for further study.

In Psychology Today, Rutgers University psychology professor Lee Jussim described the PLOS-mandated rewrite of the paper as an "Orwellian correction" where no errors had existed, merely "adding some additional discussion about limitations to the work and some minor reframing", but said the process of peer review had improved the paper.

Academic

Shortly after PLOS One published the corrected study, a critique of the original study's methodology appeared in Archives of Sexual Behavior. In a letter to the editor, Littman responded with a side-by-side comparison, stating that the criticized methodologies were consistent with those that had been used, without controversy, in widely-cited studies supporting gender identity affirmation health care.

A number of clinicians who provide care for gender dysphoric youth state that what was described in Littman's research is consistent with their patient population. Several additional reports published since the PLOS article republication note a novel large adolescent cohort presenting with gender dysphoria. There is speculation about the reasons for the observed increased incidence, including more available treatment, increased awareness or influence via social media and the internet, and increased societal acceptance of gender identity variance.

Professional commentary

Following publication of the original report in PLOS One, the World Professional Association for Transgender Health (WPATH) released a position paper on the proposed term "rapid onset gender dysphoria" and the research, stating that the term is not recognized by any professional association, nor listed in the DSM or ICD lists of disorders and diseases. They said in summary "it is nothing more than an acronym created to describe a proposed clinical phenomenon that may or may not warrant further peer-reviewed scientific investigation." They affirmed the need for academic freedom and scientific exploration without censorship, and that much is still unknown about the factors contributing to the development of gender identity in young people, and said it was "premature and inappropriate" to use "official-sounding labels" that might influence professionals or the public to reach conclusions about how or when adolescents decide to come out as transgender. WPATH concluded by warning against the use of any term intended to cause fear about an adolescent's possible transgender status with the goal of avoiding or deterring them from accessing the appropriate treatment, in line with the Standards of Care appropriate for the situation.

The Gender Dysphoria Affirmative Working Group (GDA) of professionals involved in transgender health wrote an open letter to Psychology Today calling the study "methodologically flawed and unethical", saying it proceeded from "an overt ideological bias", and citing previously published criticism of the study stating that it had multiple biases and flaws in its methodology. They said the survey drew subjects from "websites openly hostile to transgender youth", and failed to account for this bias, instead basing its conclusions on the beliefs of surveyed parents who presupposed the existence of ROGD. Noting that Littman had not interviewed the teens, and had no experience working with transgender youth, the GDA criticized conclusions in the initial publication of the study about how teens arrived at a trans identity, saying onset may only have been "rapid" from parents' point of view because teens often delay coming out in hostile environments or when fearing criticism.

The Pediatric and Adolescent Gender Dysphoria (GD) Working Group, a group of professional clinicians and researchers which has criticized gender-affirming guidelines adopted by organizations including the Endocrine Society and American Academy of Pediatrics, said ROGD "warrants further study." The group pointed to "the rise in the number of teens and young adults coming to identify as transgender without any significant prior history of gender dysphoria", and to both anecdotal reports and research indicating that many suffered from "mental health disorders in addition to gender dysphoria." The group expressed "concern that there may be elements of social contagion at work."