Pay attention
Gender clinicians should open their minds to ROGD, not try to close it down
The rapid-onset hypothesis in gender dysphoria—which provoked a “hissy fit” by the transgender health lobby WPATH—should be of keen interest to anyone specialising in the field.
So said clinician and researcher Dr Ken Zucker, a leading international authority on youth gender dysphoria, at a Paris conference of the watchdog groups The Little Mermaid and the Society for Evidence-Based Gender Medicine (SEGM) on June 29.
Dr Zucker, who estimated he has seen as a clinician about 2,500 children and adolescents over the decades,1 said the post-2010 flip in patient profile from mostly early-onset male cases of gender dysphoria to chiefly female patients with onset in adolescence was “a new clinical phenomenon [internationally] that clinicians who specialise in this area need to know a lot about.”
“Rapid-onset gender dysphoria” (ROGD) was first described in 2018 by US physician and researcher Dr Lisa Littman, whose peer-reviewed paper suggested social and online influence as a cause of clusters of friends suddenly declaring a transgender identity without the early childhood history of gender distress typical of classic gender dysphoria. These minors, chiefly girls, often had pre-existing mental health or neurodivergent issues.
Trans activist pressure on the journal that published the Littman paper resulted in a misleadingly titled “correction”, which did not significantly alter Dr Littman’s findings. Ever since, champions of the “gender-affirming” treatment approach—who often assert that trans identity is inborn and immutable—claim that the ROGD hypothesis has been debunked.
Video: US detransitioner Helena Kerschner looks in the mirror of ROGD
Interviewer: You think that the data demonstrates that [the surge in gender dysphoria] is above and beyond just the phenomenon of ‘coming out’ in an increased awareness? Jonathan Haidt: Yes, because it happens in clusters of girls who had no previous gender dysphoria when they were young. So, it’s very different from the kinds of gender dysphoria cases that we’ve known about for decades… what has happened, especially when girls got YouTube and Instagram early, but then especially TikTok—girls get sucked into these vortices and they take on each other’s purported mental illnesses.”— Social psychologist Jonathan Haidt, author of the book The Anxious Generation, PBS interview, 29 March 20242
Science opted out
SEGM co-founder and health researcher Zhenya Abbruzzese told the Paris conference she believed the politicisation of gender medicine as an issue was the result of a failure by medical authorities to debate ROGD in good faith.
“After Lisa Littman came up with a hypothesis, which was so self-evidently plausible, the American scientific establishment—instead of taking this hypothesis on board and trying to figure out what its implications are—decided to fight it vehemently and to demonise Lisa and everybody who is associated with what has become a four-letter word—‘ROGD’,” Ms Abbruzzese said.
“The scientific establishment refused to deal with the issue just as the issue got bigger and bigger… It has to be dealt with. So, the only arena that is left is that of community debates, public debates.”
She said that despite popular negativity about the political class, “politicians in democracy are representatives of the people and so, the debates that we’re seeing in the political arenas are really societal debates that are starting to play out precisely because the medical establishment failed to self-correct.”
“It is hard to deny that Littman’s research has made an important contribution to the discourse. It is now the task of the scientific community to take up this contribution and build on it with further research. We have to face the fact that ROGD may provide a convenient pathogenic explanatory model for those who are fundamentally opposed to medical transitioning of adolescents. In our opinion, however, the correct response to such possible tendencies is not to suppress research in this direction, but to strengthen it, so that evidence-based judgments of its validity are possible.”—Leonhardt el al, journal article, Neuro-psychiatre, 1 July 2024
Teen trend
Dr Littman, who also spoke at last month’s Paris conference, said it would be surprising if psychological and social factors among teenagers—including peer group influence and social media—were not to be considered in research trying to explain the dramatic flip in the profile of patients internationally.
Gender-affirming advocates who dismiss ROGD attribute the explosion of gender clinic caseloads to greater acceptance of trans identity socially,3 positive media coverage and wider availability of treatments such as puberty blockers.
In Paris, Dr Littman conceded these factors “could explain why there is a tremendous increase in the numbers, [but] it doesn’t explain why this increase is predominantly in teenagers, why is the sex ratio reversed, and why is there a new presentation of gender dysphoria—late onset in females?”
Despite the heavy pushback, she said “the evidence to support the ROGD hypothesis is early but growing.”
Her original 2018 study was criticised for relying on the accounts of parents,4 but Dr Littman said more recent research had also found support for ROGD in stories of young people themselves who had “desisted” from a trans identity or detransitioned after medical intervention.
She said their experiences of trans identification included factors consistent with ROGD—such as social influences, maladaptive coping mechanisms, misinterpreting the symptoms of a mental health condition or trauma as gender dysphoria, and difficulty accepting oneself as gay, lesbian or bisexual.
“Though [the gender-affirming lobby] WPATH publicly attacks the idea of ‘Rapid-Onset Gender Dysphoria,’ its members confess privately that they ‘cannot outright dismiss the fact that social factors’ ‘impact identity development and decision making in adolescents.’ ‘There do not yet exist any cohort studies of people with adolescent-onset gender dysphoria,’ though that hasn’t stopped WPATH from recommending hormones and surgeries for the unstudied group.”—Motion by the state of Alabama defending its ban on paediatric gender transition and drawing on subpoenaed WPATH emails, US District Court, 26 June 2024
Curiosity as a taboo
In Paris, Dr Zucker said the World Professional Association for Transgender Health (WPATH), which spearheads the gender-affirming approach, had “a hissy fit” when ROGD was first proposed.
“There is a propensity among the gender-affirming clinicians to basically say, you shouldn’t be thinking about underlying factors [in gender dysphoria]. That takes time, to look at underlying factors,” he said.
“The gender-affirming approach says it is invalidating [of trans identity] to even ask questions about why somebody might be experiencing gender dysphoria.
“I’m a dinosaur, you know, I started working as a clinician in the 1970s, and the idea that one shouldn’t be curious about why a person is experiencing symptoms… just puzzles me tremendously.
“We don’t have new psychiatric diagnoses or subtypes coming along every other week, [so this is] a really interesting development that’s happened.”
To WPATH’s objection that ROGD was not a formal diagnosis, Dr Zucker’s rejoinder was “big deal.”5
“This is a new clinical phenomenon that takes time [to be established as a diagnosis],” he said.
“How long was ‘borderline personality’ talked about in the literature, going back to the 1930s and 40s, before it made its way into the [psychiatric diagnostic manual] DSM in 1980?
“How long did it take for ‘binge-eating disorder’ to make its way into the DSM-5 in 2013?”
Dr Zucker said the ROGD hypothesis forced clinicians to think about the conceptual underpinning and understanding of gender dysphoria.
“I think that ROGD has made some of the folks in the gender-affirming school very anxious because a deep-structure perspective of the gender-affirming school of thought is essentialism—that one is born this way,” he said.
‘I’ve done biological research on gender dysphoria for many years, along with psychosocial work, and it’s just ridiculously simplistic to think that it’s entirely biological.”6
He said the advent of ROGD had also made its critics nervous about clinical management because today’s gender services were giving hormonal interventions to patients who would not have qualified for treatment under the original Dutch protocol, which is supposed to represent the foundational evidence for practice.
“One of the eligibility criteria [of the protocol] was that you had to have a lifelong, persistent history of gender dysphoria, or gender non-conforming behaviour—well, ROGD kids completely challenged that eligibility criterion,” he said.
Dr Zucker gave the example of a gender clinician seeing for the first time a 13-year-old where both the parents and the minor agreed that gender dysphoria had only been present for the last three months.
“[Under the Dutch protocol,] that should be a rule-out for consideration of hormonal suppression [with puberty blockers],” he said.
“[But] if you don’t take the Dutch eligibility criteria seriously,7 what do you do with these kids?
“I can tell you what the gender-affirming clinics I have experience with do with these kids, they ignore the Dutch eligibility criteria and will recommend blockers or cross-sex hormones anyways, because they need for all of the kids to fit into the ‘this is just the way they are’ model.”
Dr Zucker chaired the 2007-13 work group which adopted gender dysphoria in the diagnostic manual DSM-5 in 2013; this replaced the term “gender identity disorder”. He worked for 40 years at the pioneering Toronto clinic before gender-affirming activists helped engineer his dismissal. The “external review” cited as justification for this decision appears to have been a charade. Dr Zucker took legal action and was vindicated. Misinformation about his dismissal continues to be spread by activists. He has also come under pressure as editor of the journal Archives of Sexual Behavior because it has been one of the few scholarly publications willing to accept papers with findings deemed unacceptable to the dogmatic gender-affirming worldview.
A review of the book The Anxious Generation in the magazine City Journal notes: “Haidt also recounts concerning examples of social contagion, such as viral posts by users with Tourette Syndrome prompting an exploding number of teenage girls to develop tics. One of the main treatments prescribed by doctors? Get off social media. Diagnoses of gender dysphoria, as well, may be related to social media trends. Recent years have seen a staggering increase in clinical referrals for Gen Z teens with the condition, particularly girls.” Washington Post columnist Megan McArdle finds the social contagion thesis credible: “I don’t have any peer-reviewed studies, but I do have extensive experience being a high school girl with an eating disorder, and the dynamic seemed very obvious when I first went on TikTok.”
Yet activists also insist that levels of “transphobia” are dangerously high. How this co-exists with greater acceptance is not explained.
Researchers of the gender-affirming persuasion have published papers making use of the accounts of parents without their methodology being criticised. The original Littman study acknowledged limitations to do with reliance on parental reports, including the possibility that some parents might fail to notice early signs of gender distress. The 2018 paper also flagged the potential bias arising from the decision to target primarily websites where the phenomenon of ROGD was being discussed.
In stating that ROGD is not a formal diagnosis, critics of Dr Littman’s research may give the impression that she had made such a claim. In fact, she framed her 2018 paper as a preliminary attempt to generate hypotheses warranting further research.
In her April report, Dr Hilary Cass said: “For children and young people with gender incongruence, ‘innate’ or biological factors may play a part in some individuals, in ways that are not yet understood, and in others psychosocial factors, including life experiences, societal and cultural influences, may be more important. Since biological factors have not changed in the last 10 years, it is necessary to look at other possible reasons for the increase in referrals and the disproportionate representation of birth-registered females.”
In Finland, the first country to shift to caution on gender dysphoria treatment, the new 2020 policy looked rather like the original Dutch approach in its emphasis on patients having to show “significant and prolonged gender conflict that causes reliably identifiable and harmful suffering in everyday situations.”
Thank you Bernard for all the information you give us. As a parent of a son lost to ROGD it helps me to understand what has happened. He had never shown any problems until Covid struck and he was constantly online. I'm sure that's where he was influenced.
It is pathetic to see how the Affirmative Model zealots claim that they follow the evidence.
The main evidence they follow is from the Dutch papers which have been severely criticised. Yet they do not even follow the eligibility criteria used in the Dutch protocols which would have excluded all children with ROGD.