On August 16, 2018, the open-access journal PLoS ONE published an article on its website that caused such an outcry from both the scientific community and the lay public that the editors asked the author to revise the paper to address these concerns. It is not uncommon for an article in a scientific journal to go viral in the public media, nor is it unusual for academics to bicker about the merits of a particular study. However, it is rare indeed for editors of an academic journal to yield to pressure from the lay public, even going so far as to issue an apology for having offended some of their readers, yet this is exactly what happened. Scientific innovation and progress inevitably challenge established ways of thinking. Was this article bad science or was the pushback simply bad faith on the part of those who found the new ideas threatening?
The Controversy
The article in question was written by Lisa Littman, a physician and medical researcher at Brown University. In this article she described a phenomenon she called “rapid-onset gender dysphoria” (1). The data detailing this phenomenon were garnered from surveys completed by parents of trans youth, mostly female, who had shown no sign of gender nonconformity in childhood but instead had first mentioned their desire to transition only after a later period of documented mental illness. These parents also reported that their children had only declared their gender dysphoria after interactions on social media with trans and gender-dysphoric peers. Thus, Littman concluded, there may be some gender-nonconforming youth who do not follow the normal trajectory of gender dysphoria. Furthermore, she proposed that in such cases feelings of gender mismatch may be due to social contagion rather than biological processes. The author concluded by urging researchers in the field to look more deeply into the issue.
Ending a journal article with the caveat, “more research is needed,” is simply an exercise in academic integrity. It’s exceedingly rare for a single journal article to reshape the scientific consensus on an issue and certainly never in the case of a brief descriptive study such as the one that Littman presented. I read Littman’s article when it was first published and, while I felt that she was describing a phenomenon worthy of further study, I got no sense that she was pushing an agenda, or at least no more so than any other journal article does. However, this was not the way that many people read Littman’s piece.
Reactions to Littman’s proposal of “rapid-onset gender dysphoria” came from all directions. There was an outpouring of support from parents of trans teens who felt validated in their concern that their children had misattributed their psychological distress to gender dysphoria after being encouraged to do so by peers (2). Likewise, there were positive responses from clinicians who had also noticed an increasing number of adolescent and young adult women reporting gender dysphoria against a background of psychological distress (3).
At the same time, the editors of PLoS ONE received strident objections from academia and the trans community alike. For instance, Brown University psychologist Arjee Restar accused Littman of “pathologizing” gender dysphoria as well as criticizing her for not selecting a representative sample of trans youth parents (4), and, in a series of essays, trans activist and University of Alberta law professor Florence Ashley condemned Littman’s article on rapid-onset gender dysphoria as “bad science” (5). These academics especially took issue with Littman’s speculation that gender dysphoria had spread through the study group as social contagion, arguing instead that the gender nonconforming youths were just seeking out likeminded peers. These critics also pointed out that conservative lawmakers were using the notion of gender-dysphoria-as-social-contagion to justify their anti-trans agendas.
In response to these protests, the editors asked Littman to revise her article (6). In particular, she had to clarify that she was using the term “rapid-onset gender dysphoria” as a descriptor for a putative phenomenon and not as a diagnostic label. I thought that position had been made clear in the original version of the article. But since PLoS ONE is an open-access journal, meaning that anyone can access it without going through a paywall, my guess is that the editors felt they needed to clarify the nature of the study for the significant lay audience that had also read the paper. Furthermore, then editor-in-chief Joerg Heber publicly apologized “to the trans and gender variant community for oversights that occurred during the original assessment of the study”. The revised version of Littman’s paper is now posted on the journal’s web site, although the original version is also available there.
The reaction from trans activists was to be expected. After all, the trans community still faces significant discrimination. In addition, trans activists rightly fear any scientific findings challenging the received wisdom that all gender nonconforming individuals are born that way, since these findings can be used by conservative lawmakers to bolster their anti-trans agendas. While I understand this concern, I think the answer is not to stifle science that yields politically inconvenient findings but rather to boldly condemn the immorality of any legislation enacted with the intention of marginalizing a specific group.
The rather vitriolic attack from fellow clinicians was perhaps unexpected in advance but understandable in hindsight. Ideally, scientists seek truth and evaluate evidence in a dispassionate fashion. In reality, however, scientists are ordinary humans and they can get defensive if they believe that their pet theories are being challenged (2). To understand why some clinicians reacted so negatively to Littman’s notion of early-onset gender dysphoria, we need to first review current thinking on the origins of gender dysphoria and the best clinical practices for helping gender-nonconforming individuals to lead fulfilling lives.
Types of Gender Dysphoria
The term “gender dysphoria” refers to the psychological distress a person experiences when they feel a mismatch between their biological sex and their psychological gender. Expressions such as “feeling like a man trapped in a woman’s body” and “born the wrong sex” are not uncommon. Gender nonconformity is no longer seen as a disorder in itself, although it can lead to significant distress as the individual tries to reconcile self-identity with societal expectations.
It is important to understand that not all gender-nonconforming individuals follow the same developmental trajectory. The classic form is known as early-onset gender dysphoria, in which gender nonconforming behaviors emerge in the preschool years, that is, when gender identity first forms (2). The scientific consensus is that early-onset gender dysphoria can be traced back to prenatal development (15). Given that we all start out with a female body plan, it should come as no surprise that in some cases the brain develops in one sex-typical fashion while the body does so in another (15). Although sex differences in the brain are small, they are important as they deal with processes such as brain-body mapping and sexual orientation. Thus, it is clear that individuals with early-onset are born that way. Furthermore, the incidence of early-onset gender dysphoria is equally divided between natal males and natal females.
A second type of gender dysphoria is known as “late onset,” since it first appears during or after puberty (2). Although this form of gender dysphoria has been studied for decades, there is still some disagreement among experts as to its etiology. Northwestern University psychologist Michael Bailey, basing his theory on earlier work done by Canadian psychologist Ray Blanchard, argued that late-onset gender dysphoria arises almost exclusively in men and as a form of sexual fetish in which they become aroused by dressing as a woman and imagining themselves as having a woman’s body (7). Although the gender-nonconforming behavior does not emerge until puberty or later, Bailey and Blanchard maintain that its roots still lie in prenatal development.
The notion of late-onset gender dysphoria is controversial. Trans activists generally dismiss the distinction between early and late onset, given that gender nonconformance is believed to be innate in both cases. Some clinicians agree with this assessment for the same reason, maintaining that individuals may harbor feelings of gender nonconformity for years before opening up about them (8). Other researchers in the field, however, consider that the developmental trajectory as well as the specific gender-nonconforming behaviors are sufficiently different to warrant a separate category.
Rapid-onset gender dysphoria, if confirmed as a separate diagnostic category, would constitute a third variety of gender nonconformance. Furthermore, its characteristics are considerably different from the other two types. First, feelings of sex-gender mismatch come on over a short period of time, hence the term “rapid-onset.” Second, gender dysphoria is believed to arise through social contagion rather than prenatal development. Because both the trans community and the clinicians who care for them have bought into the theory that all gender dysphoria has its roots in prenatal development, the idea that it could sometimes arise from social influence is viewed as a dangerous challenge to the received wisdom.
Models of Gender Health Care
The standard model for the therapeutic care of persons suffering from gender dysphoria was developed in the Netherlands in the 1990s and hence is known as the “Dutch Model” (2). Designed specifically to treat early-onset gender dysphoria, the Dutch Model consists of extensive counseling with medical and surgical treatment as necessary, determined on a case-by-case basis. The goal of counseling is not to persuade or dissuade the person regarding transitioning, but rather to help them understand their own feelings and to create a realistic outlook on what life as the other gender will be like. Puberty blockers are administered to give the young person more time to assess their gender identity, and then if the dysphoria persists, cross-sex hormone therapy begins. Surgery, if the person desires it, is done after reaching the age of majority. The family is also involved in the process with the recognition that transitioning will only be successful if the person has adequate social support.
In the United States, a variant of the Dutch Model known as the Gender Affirmative Model is frequently used (9). Like the Dutch Model, it involves extensive counseling with the gender-variant child as well as with family members, and the goal is to help the child understand their gender identity. Practitioners of this model take the position that both counselors and family members alike need to listen to the child, since only the person concerned can truly understand their gender identity. Unlike the Dutch model, however, the Gender Affirmative Model advocates for medical and surgical interventions as soon as the child feels ready to begin, rather than taking a “wait and see” approach.
Rise in Cases of Gender Dysphoria
Historically, the incidence of persons reporting to clinics with feelings of gender dysphoria has been quite low. However, over the last decade, there has been a dramatic increase in the rate of referrals (10). There are likely a number of contributing factors (2). First, information about transgender issues is more freely available in print, on TV, and on the internet, so young people experiencing feelings of gender nonconformity have access to plenty of information that can help them achieve some level of understanding of their gender identity and, in particular, that they are not alone. Second, clinicians no longer view gender dysphoria as a disorder and the general public is now much more accepting of gender nonconformity than in the past, even though pockets of resistance still remain. Finally, the availability of medical and surgical treatments offers the hope of living according one’s true gender identity. For all these reasons, young people today with questions about their gender identity are more willing to seek out help than in the past.
At the same time, the balance of natal males to natal females seeking gender health care has shifted from a predominance of males to females (11). Until about a decade ago, more males than females sought gender-affirming therapies, which makes sense, given the even numbers of males and females in the case of early-onset gender dysphoria and the almost exclusive incidence of males in the case of the late-onset variety.
The switch to a preponderance of females seeking gender health care is an established fact accepted by all parties. However, the reason for this change is hotly debated. On the one hand, it could be that natal females now feel more empowered to live according to their truly-felt gender identity (5). In the past, according to this view, feminine men were much less tolerated than masculine women, so males were more likely to seek treatment. It may also be the case that gender dysphoria has always been more common among natal females, but only recently have they presented themselves in their true numbers. On the other hand, this shift in trend might instead be explained by the rise of rapid-onset gender dysphoria, which occurs predominantly in females, thus tipping the balance.
A Survey of Detransitioners
Since her initial article and the furor that it aroused, Lisa Littman has become an ardent advocate for the position that rapid-onset gender dysphoria is a phenomenon that needs to be taken seriously (12). She has defended her research methods against accusations that they were inappropriate, noting that parental surveys are frequently used in the clinical literature. Even though only the children themselves can know what they are experiencing, parents can provide important behavioral or situational insights that the children may not have. Thus, starting with the parents’ perspective was a reasonable entrance into the topic.
Littman’s next research project focused on youth who had transitioned but later chose to return to their natal sex (13). Among these, more than two-thirds were natal females. Although they gave a variety of reasons for detransitioning, more than half stated that they had become comfortable living as their natal sex, and more than a third believed they their gender dysphoria had stemmed from psychological distress rather than the other way around. In interviews, some of these detransitioners reported experiences just like those Littman described in her original article, namely, that detransitioners had been experiencing psychological issues for some time before coming across web sites suggesting that their distress could be due to gender dysphoria. They then sought out peers online who confirmed this perception and, with the hope that transitioning would alleviate their psychological anguish, they came out as trans.
From the point of view of Littman and her supporters, this evidence provides additional support for the contention that rapid-onset gender dysphoria is a real phenomenon and that—unlike other forms of gender nonconformity—the origin of rapid-onset gender dysphoria is in social contagion, not prenatal development. In contrast, those who remain unconvinced that rapid-onset gender dysphoria is a real phenomenon maintain that the gender dysphoria was there all along and it took interactions with trans peers to understand the source of the psychological distress (5). Furthermore, a quarter of the respondents cited discrimination as a reason for detransitioning, meaning that, even though they would have been happy living as trans, they felt safer presenting themselves as their natal sex.
The Controversy, Round Two
On 29 March 2023, Suzanna Diaz and Michael Bailey published an article in the journal Archives of Sexual Behavior that claimed to provide further evidence for rapid-onset gender dysphoria (14). Diaz is the pseudonym for a stakeholder of the website ParentsofROGDKids.com, and Bailey is the Northwest University psychologist we met in our earlier discussion of late-onset gender dysphoria. In their article, Diaz and Bailey report on a survey of 1,655 parents of youths who had transitioned, three quarters of whom were natal females. The parents reported that their children had suffered extensive periods of psychological distress before coming out as trans, and that many of these parents also felt pressured by clinical staff to accept and support their child’s transition, even though the parents felt it was inappropriate.
It should come as no surprise that this article also raised a furor among trans activists and clinicians working under the General Affirmative Model (L4). Detractors not only denounced the authors of the article but also Kenneth Zucker, editor-in-chief of the journal, for publishing questionable research. They criticized the first author for collecting data without first obtaining informed consent from the respondents to publish their data, and they faulted the second author for not obtaining prior approval from his institutional review board.
My understanding from reading this article is that Diaz collected the data informally on her website and later approached Bailey about publishing it. Ordinarily, researchers seek approval from their affiliation’s institutional review board before collecting data. However, Diaz was not affiliated with any university, so she would not have taken this step. When she handed the data she had collected to Bailey, he submitted a proposal to Northwestern University’s institutional review board, which decided that he did not need approval to report data that had been previously collected for other purposes. I have served on institutional review boards and I think the decision in this case was reasonable. Furthermore, it is not at all uncommon for researchers to make use of data that people have publicly posted on the internet without seeking their informed consent. To my mind, these accusations of unethical conduct smack of a disingenuous attempt to squash research findings that are unfavorable to the accusers’ pet theory.
I read the Diaz and Bailey article shortly after it was published and in my opinion the authors clearly explained how the data were obtained and the limitations of the study. Also, the data set was much larger than Littman’s original study, with over six times the number of respondents. After having read both articles, I feel convinced that rapid-onset gender dysphoria is a phenomenon worthy of further study while remaining agnostic as to the outcome.
Under pressure from critics, the editors of the Archives of Sexual Behavior retracted the article by Diaz and Bailey on 14 June 2023. It remains to be seen whether a revised version of the article addressing the concerns of critics will be published at a later date, as was the case with Littman’s 2018 paper. While we want our academic journals to maintain the highest ethical standards and to remedy errors when they are made, it is disturbing to see that editors can be cowed into suppressing research findings that threaten received wisdom and accepted practice.
If it is indeed true that some cases of gender dysphoria originate in social contagion rather than prenatal development, there are important clinical implications. At the very least, clinicians should explore this possibility with their clients as part of the therapy process. And while there is ample evidence that transitioning can have a significantly positive impact on the quality of life for those suffering from early-onset gender dysphoria, transitioning could very well have deleterious results for those who misconstrue psychological distress due to other causes as gender dysphoria. It could also turn out that rapid-onset gender dysphoria is not essentially different from the standard early-onset variety and should therefore be treated the same way. If scientists are free to conduct further research on this topic then at least we will know for sure.
So far, the fiery debate over rapid-onset gender dysphoria has generated much heat but little light. Trans activists should realize that their opponents are politicians pushing agendas that restrict gender-affirming treatments, not scientists trying to deepen our understanding of this very complex issue. Likewise, clinicians should read new studies that contradict received wisdom with an open mind, as this is way that science progresses. In the end, the science will not be decided by the loudest voice or the cleverest argument but by the incremental and painstaking accumulation of evidence and by the freedom to ask any question, no matter how uncomfortable it may make us feel. After all, scientists, clinicians, and trans activists all have the same goal, namely to understand the nature of gender dysphoria so that we can find effective ways to help those who suffer from it to lead happy and productive lives.
David Ludden
References:
- Littman, L., “Rapid-onset gender dysphoria in adolescents and young adults: A study of parental reports”, PLoS ONE, 2018.
- Zucker, K. J., “Adolescents with gender dysphoria: Reflections on some contemporary clinical and research issues”, Archives of Sexual Behavior, 2019.
- Hutchinson, A. et al., “In support of research into rapid-onset gender dysphoria”, Archives of Sexual Behavior, 2020.
- Restar, A. J., “Methodological critique of Littman’s (2018) parental-respondents accounts of ‘rapid-onset gender dysphoria’”, Archives of Sexual Behavior, 2019.
- Ashley, F., “A critical commentary on ‘rapid-onset gender dysphoria’”, The Sociological Review Monographs, 2020.
- Littman, L., “Correction: Parent reports of adolescents and young adults perceived to show signs of a rapid onset of gender dysphoria”, PLoS ONE, 2019.
- Bailey, J. M., “The man who would be queen: The science of gender-bending and transsexualism,” 2003.
- Zaliznyak, M. et al., “How early in life do transgender adults begin to experience gender dysphoria? Why this matters for patients, providers, and for our healthcare system”, 2021.
- Keo-Meier, C. and Ehrensaft, D., “The gender affirmative model: An interdisciplinary approach to supporting transgender and gender expansive children”, 2018.
- Arnoldussen, M. et al., “Re-evaluation of the Dutch approach: Are recently referred transgender youth different compared to earlier referrals?”, European Child & Adolescent Psychiatry, 2020.
- Aitken, M. et al., “Evidence for an altered sex ratio in clinic-referred adolescents with gender dysphoria”, Journal of Sexual Medicine, 2015.
- Littman, L., “The use of methodologies in Littman (2018) is consistent with the use of methodologies in other studies contributing to the field of gender dysphoria research: Response to Restar (2019)”, Archives of Sexual Behavior, 2020.
- Littman, L., “Individuals treated for gender dysphoria with medical and/or surgical transition who subsequently detransitioned: A survey of 100 detransitioners”, Archives of Sexual Behavior, 2021.
- Diaz, S. and Bailey, M., “Rapid onset gender dysphoria: Parents reports on 1655 possible cases”, Archives of Sexual Behavior, 2023.
- Altinay, M. and Anand, A., “Neuroimaging gender dysphoria: A novel psychobiological model”, Brain Imaging and Behavior, 2019.
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