Rapid-onset gender dysphoria controversy
The rapid-onset gender dysphoria controversy centers around the concept of rapid-onset gender dysphoria (ROGD), proposed to be a subtype of gender dysphoria caused by peer influence and social contagion. It has never been recognized by any major professional association as a valid mental health diagnosis, and its use has been discouraged by the American Psychological Association, the American Psychiatric Association, the World Professional Association for Transgender Health, and other medical organizations due to a lack of reputable scientific evidence for the concept. Lisa Littman, as an adjunct assistant professor at the Icahn School  of Medicine at Mount Sinai, created the term based on an online survey of parents on three anti-transgender websites who believed that their teenage children had suddenly manifested symptoms of gender dysphoria and begun 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. In August 2018, Littman (then an assistant professor of the practice at the Brown University School of Public Health) published a descriptive study in "PLOS One". Criticism of the study's methodology and conclusions was voiced by  some clinicians, researchers, and transgender activists, and two weeks after publication, "PLOS One" responded by announcing a post-publication review of the paper. On the same day as "PLOS One" announced its post-publication review, Brown University retracted its press release promoting the study. Controversy surrounding the paper 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. In March 2019, the journal concluded its review and republished Littman's revised and corrected version. Other  researchers have since remarked on a much increased incidence of youth seeking care for gender dysphoria, the cause of which remains to be established. In 2021, the American Psychological Association and the American Psychiatric Association cosigned a statement with 120 other medical organizations calling for ROGD not to be used in diagnostic or clinical settings due to a lack of reputable scientific evidence for the concept. The statement also criticized the proliferation of misinformation supporting the concept of ROGD targeted at parents and clinicians and the concept's use to justify laws targeting the rights of transgender youth in the  United States. A November 2021 study published in the "Journal of Pediatrics" analyzed clinical data of teenagers seen in gender clinics and found no support for ROGD being a distinct phenomenon. The authors found no link between more recent onset of gender dysphoria and other mental health problems, and no link between recent onset and a high level of support from online or transgender friends. Original 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, then an adjunct assistant professor at the Icahn School of Medicine at Mount Sinai, became interested in the possible role of social contagion in gender dysphoria  among young people, and conducted a study by collecting 256 responses from an online survey, which was not randomly distributed, but rather targeted at parents recruited from three anti-transgender websites where she had seen parents describe what they believed were sudden gender transitions in their adolescents: "4thWaveNow", "Transgender Trend", and "Youth TransCritical Professionals". Littman said she encouraged wide distribution of the survey beyond these three sites, but the study states that participants were encouraged to distribute the study only to "individuals or communities that they thought might include eligible participants," which the study defined as parents who believed "their  child had a sudden or rapid onset of gender dysphoria," thus using another nonprobability sampling method known as "snowball sampling." Of the three websites, an article published in "Science" described the first two as "gathering places for parents concerned by their children's exploration of a transgender identity", with the third being closed to non-members. Bioethicist Florence Ashley described the first as "dedicated to opposing gender-affirmative care for trans youth", and the latter two as dedicated to opposing what they call "trans ideology". More than three-quarters of the parents surveyed had rejected their child's transgender identity . Arjee Restar, a behavioral health researcher then also at the Brown School of Public Health, wrote that the three sites were frequented by parents who already specifically promoted the concept of ROGD and that the websites were "known for telling parents not to believe their child is transgender". Littman's study described what the surveyed parents believed to be a rapid onset of gender dysphoria among their children, along with information the parents reported about their 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. Littman presented preliminary results at a 2017 conference, and the descriptive study was initially published in "PLOS One" in August 2018. Correction. The paper was met with criticism from health researchers, transgender activists, and others, 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 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: "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". Littman notes that "Rapid-onset gender dysphoria (ROGD) is not a formal mental health diagnosis  at this time." She wrote: 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. Institutional. On the same day that "PLOS One" announced its review, Brown University took down a press release it had earlier posted about the paper. Responding to critics, Brown University president Christina Paxson and Provost Richard M. 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. Several critiques of sociological aspects of the study have been published in peer-reviewed journals. In a 2020 paper published in The Sociological Review, bioethicist Florence Ashley described the study as an attempt to circumvent existing research supporting gender-affirming care. Sociologists Natacha Kennedy and Victoria Pitts-Taylor, in two separate 2020 publications  in the Journal of LGBT Youth and "Sexualities", described ROGD as a moral panic and argued that trans youth are often aware of their identity long before coming out to their parents. 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", called for further study into the proposed phenomenon. Writer and transgender advocate Liz Duck-Chong described the hypothesized condition as "a poisonous lie used to discredit trans people" in the op-ed section of "The Guardian", while Abigail Shrier, who later  published the controversial book "Irreversible Damage" about the concept, called it an explanation for the experiences of parents in the op-ed section of "The Wall Street Journal". In a Psychology Today opinion piece, Rutgers University psychology professor Lee Jussim described the PLOS-mandated rewrite of the paper as an "Orwellian correction" involving some additions and minor changes where no errors had existed. Jeffrey Flier, a former dean of Harvard Medical School, said that Brown was valuing diversity over academic freedom and called the retraction a "cautionary tale" about pressure from social media, calling for a movement to support academics  conducting controversial research. Academic. Shortly after "PLOS One" published the corrected study, a critique of the original study's methodology appeared in "Archives of Sexual Behavior". The author, Arjee Restar, argued that Littman's study was fatally methodologically flawed, beginning with the choice to sample exclusively from users of three websites "known for telling parents not to believe their child is transgender," with the result that three-quarters of those surveyed had rejected their child's gender identity; 91 percent of respondents were white, 82 percent were women, and 66 percent were between the ages of 46 and 60. She  wrote that the study was mostly composed of "white mothers who have strong oppositional beliefs about their children’s trans identification" and that there was very little evidence that Littman's survey responses were representative of trans youth and young adults as a whole. In a letter to the editor, Littman responded by arguing that her methodologies were consistent with those that had been used, without controversy, in widely-cited studies supporting gender identity affirmation health care. Some clinicians state that an increasing prevalence of trans youth first presenting in early adolescence, as described in Littman's research, is consistent  with their patient population, though they are uncertain as to causes or implications for clinical treatment. In a 2020 commentary in "Pediatrics", citing Littman's paper among others, Annelou de Vries wrote that gender identity development was diverse and called for more research into this demographic cohort. 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 44 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 20 professionals said that ROGD warranted further study. The group pointed to an increase in the number of teenagers coming out as transgender "without any significant prior history of gender dysphoria" and to both anecdotal reports and research indicating that many of them suffered from mental health disorders. In 2021, the Coalition for the Advancement and Application of Psychological Science released a statement calling for the elimination of the concept of ROGD from clinical and diagnostic use, as "there are no sound empirical studies of ROGD and it has not been subjected to rigorous peer -review processes that are standard for clinical science." The statement also states that the term "ROGD" is likely to stigmatize and cause harm to transgender people, and that misinformation surrounding ROGD is used to justify laws suppressing the rights of transgender youth. The statement was cosigned by the American Psychiatric Association, the American Psychological Association, the Society of Behavioral Medicine, the Association for Behavioral and Cognitive Therapies, and the National Association of School Psychologists. Further research. A November 2021 study published in the "Journal of Pediatrics" examined data on a cohort of 173 trans adolescents from Canada to assess whether  there was evidence for a rapid-onset pathway for gender dysphoria. The authors noted that while it was common to see adolescents presenting with gender dysphoria around puberty, in many cases patients had been aware of gender dysphoria from a younger age. The authors sought to establish whether there was any link between later awareness of gender ("rapid onset") and other factors including mental health problems, lack of parental support, and high level of support from online and/or transgender friends. No evidence was found for any link between "rapid onset" and mental health problems, lack of parental support, or high  level of support from online or transgender friends. Where relationships were found, they were in the opposite direction to that suggested by Littman's work—for instance, trans adolescents who had been dissatisfied with their gender for longer were more likely to suffer anxiety and more likely to misuse marijuana. The authors considered that they found no evidence of "rapid onset gender dysphoria" being a distinct clinical phenomenon.