A new study examining 1,655 parental reports lends further credibility to the rapid onset gender dysphoria (ROGD) hypothesis, first posited by Dr. Lisa Littman in 2018. The ROGD hypothesis suggests that the recent surge in transgender-identifying adolescents is explained, at least in part, by a rise in the number of previously gender-normative teens who developed gender-related distress in response to various psychosocial factors (e.g., mental health conditions, internalized homophobia, trauma, etc.). Opponents of the ROGD hypothesis claim that the surge is merely the result of greater acceptance of transgender identities by society, and hence, a greater willingness among “intrinsically transgender” adolescents to “come out.”
If true, the ROGD hypothesis challenges the premise of gender affirmation, which demands that healthcare providers confirm an adolescent’s self-identification and facilitate access to any and all desired hormonal and surgical interventions that bring young people’s bodies in line with their current gender identity. It is likely for this reason that the ROGD hypothesis generated such harsh opposition from the proponents of gender-affirming care.
At the demand of activist researchers, Littman’s paper was subjected to a rare second round of post-publication peer review. The paper was later republished with a clearer description of the methodology (emphasizing its reliance on parental reports), but with its conclusions of a likely role of ROGD intact. To date, Littman's paper has been downloaded more than half a million times.
The new study, co-authored by Suzanna Diaz and J. Michael Bailey, and published this week in the Archives of Sexual Behavior, continues to rely on parental reports, pointing out that parents of gender-dysphoric youth are “influential stakeholders” and that parental reports are frequently the sources of research published by the proponents of gender affirmation. The authors conclude that “there is presently no reason to believe that reports of parents who support gender transition are more accurate than those who oppose transition.”
The new report identifies the following trends among caregivers and children, specifically:
- Over 9 in 10 are progressive, pro-LGBT rights parents (based on randomly selected 280 participants)
- Over 8 in 10 of the parent survey participants are mothers
- Over 5 in 10 caregivers referred to gender clinics felt pressures to support gender transition (based on 380 participants who answered the corresponding question)
- Prior to gender transition, the families had “close” or “neutral” relationships with their teens, with better relationships with mothers
- Following social gender transition, intra-familial bonds suffered, most severely affecting mother-child relationships
Youth (based on parental reports):
Demographics and Identity
- The female/male ratio was 3:1 (however the proportion of boys increased over the 46 months of the study)
- Females were on average two years younger at the onset of gender dysphoria than male adolescents (age 14.1 for females vs. age 16 for males)
- About 82% had a cross-sex identity and 18% were “nonbinary.” Nonbinary identities were twice as common among females
- About 85% were rated as above-average intelligence, and 36% were rated as having “exceptional intelligence”
Peer Influence/Internet/Social Media Use
- 60% of female and 38% of males adolescents had at least one friend who declared a transgender identity around the same time
- Parents estimated that their children spent about 4.5 hours per day on the Internet and social media prior to the onset of gender dysphoria, with heavier internet use among the male adolescents (5.6 hours for males vs 4.1 hours for females)
- 57% had a prior history of mental health issues and 43% had a formal mental health diagnosis
- Mental health problems preceded the onset of gender dysphoria by an average of 3.8 years
- 73% of participants reported that the child experienced a stressful event that may have contributed to the onset of gender dysphoria, such as romantic difficulties or the loss of family members
- Overall, 65% of youth were socially transitioned, with more than twice the rate of transition among females compared to males (66% vs 29%)
- Contact with “gender specialists” was associated with social transition, and roughly doubled the rate of hormonal interventions
- Youth with the greatest burden of pre-existing mental health problems were most likely to socially transition
- Mental health of youth deteriorated following gender transition
- While females were much more likely to socially transition, males were much more likely to receive hormonal interventions
- Among those whose gender dysphoria lasted for at least one year, 14% of females and 24% of males received hormonal interventions
- The rate of surgical interventions in the sample was low
The study authors reflected on a “statistically robust finding” that they called “both disturbing and seemingly important": "Youth with a history of mental health issues were especially likely to take steps to socially and medically transition.” They noted that youth with mental health problems are especially at risk since they may lack the judgement necessary to embark on irreversible, life-changing decisions.
The authors concluded with a discussion of the study limitations; the most notable was recruiting parents through a website for concerned, rather than “affirming”, parents. As a result, these parental reports may be biased, and the findings may be different from those reported by affirming parents, or by families seen in clinical settings.
The authors note that some parents strongly endorse the ROGD theory, while others vehemently oppose it. Rather than assuming that these two sets of parents differ in their underlying beliefs and attitudes, which biases their assessments of their children’s situations, it may be reasonable to conclude that the different variants of gender dysphoria in young people may lead parents to markedly different conclusions of whether the etiology of their children’s gender distress is attributable to ROGD.
In 2018, Dr. Lisa Littman put a name to the phenomenon of the rapid rise in the numbers of previously gender-normative youths declaring transgender identities in adolescence in the context of social difficulties and pre-existing mental illness. The explanations provided by the ROGD hypothesis resonated with thousands of baffled parents and experienced mental health clinicians who were equally confounded. A leading therapist at GIDS, the largest pediatric gender clinic in the world, noted:
“While some of us have informally tended toward describing the phenomenon we witness as “adolescent-onset” gender dysphoria, that is, without any notable symptom history prior to or during the early stages of puberty (certainly nothing of clinical significance), Littman’s description resonates with our clinical experiences from within the consulting room” (Hutchinson et al., 2020, p. 1)
While the adolescent-onset presentation with a preponderance of teen females with preexisting mental health issues has been reported by clinicians and all major gender clinics in the West, Littman's paper generated significant pushback about its methods from the proponents of pediatric gender transition. They criticized the paper for its reliance on parental reports, despite the fact that the study employed the same methods used by other researchers of this topic. The concept of ROGD continues to generate debate.
The key strength of the current study is its robust sample size. The study findings—the post-pubertal onset of gender dysphoria, its emergence in the context of preexisting mental health issues, and the contributing role of social media and peer influence—corroborate the phenomenon of ROGD. The fact that parents rated their children’s mental health as deteriorating following transition, and that parent-child relationships deteriorated as well, raises serious concerns about the current trend of social and medical transition of adolescents with post-pubertal onset of gender dysphoria.
The key limitation of the study is its reliance on parental reports. For this reason, it is critical to conduct research that does not solely rely on the recollections of either parents or patients, but instead, independently validates the age of onset of gender dysphoria or markedly gender-incongruent behaviors in currently-presenting adolescents by examining medical records and interviewing multiple informants. If a preponderance of early-childhood gender incongruence in the currently-presenting cohort of adolescents is confirmed, this would weaken the ROGD hypothesis. In contrast, an absence of objectively verifiable gender incongruence in early childhood, the emergence of gender dysphoria post-puberty in the context of pre-existing mental health difficulties, and clusters of cases occurring in pre-existing social networks would further support the ROGD theory.
The question of the etiology of adolescent gender-related distress is critical. Without an understanding the etiology of this condition and its natural history, the development of safe and effective treatments is challenging. This study’s findings, along with a growing number of detransitioners who have endorsed the applicability of the ROGD theory in their own lives, should prompt the medical community to take ROGD seriously. This means engaging with this very plausible theory in good faith, rather than continuing to rely on straw man arguments in a concerted clinician-activists-led effort to debunk it.