In 2018, Lisa Littman, Assistant Professor of the Practice at the Brown University School of Public Health, published an article in the peer-reviewed journal PLOS ONE entitled Rapid-Onset Gender Dysphoria in Adolescents and Young Adults: A Study of Parental Reports. The article drew attention to a phenomenon that had attracted widespread concern among parents, but which had not yet been studied systematically in the scientific literature.

Following publication, Dr. Littman and her study became the subject of intense criticism from some activists, who accused the author of spreading misconceptions about transgender people and employing biased methods. In response to this criticism, PLOS ONE initiated a re-review of Dr. Littman’s paper. This week, following the recent conclusion of that review, a modified version of Dr. Littman’s paper was published by PLOS ONE. And both Dr. Littman and PLOS One have released statements. According to the Notice of Republication, “Other than the addition of a few missing values in Table 13, the Results section is unchanged in the updated version of the article. The Competing Interests statement and the Data Availability statement have also been updated in the revised version.”

Since the original publication of her controversial article, Dr. Littman has maintained a low media profile, even as her exploration of Rapid-Onset Gender Dysphoria (ROGD), a once taboo subject, came to influence the policy debate surrounding the treatment of children and teens who present as transgender. To coincide with the republication of the paper, now titled “Parent Reports of Adolescents and Young Adults Perceived to Show Signs of a Rapid Onset of Gender Dysphoria,” Quillette Canadian editor Jonathan Kay interviewed Dr. Littman about her research. The opinions expressed in this article are those of Dr. Littman and do not necessarily reflect the position or opinions of any institution, organization or company with which she may be affiliated.

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Jonathan Kay: What is the status of your paper with PLOS ONE?

Lisa Littman: After publication, there was a storm of debate about the paper, and PLOS ONE decided to conduct a post-publication review. The post-publication review was rigorous, and included input from three senior members of the PLOS ONE editorial staff, a statistical reviewer, two academic editors, and an external expert reviewer. The manuscript was meticulously evaluated, and, in response to the resulting feedback, changes were made to several sections of the paper, though the methods and findings remained mostly unchanged. A revised version of the paper is now published along with a republication notice that explains what was changed from the original paper and expands the discussion around several key topics. The original version of the paper is available as supplemental material. Overall, I am very pleased with the final product and [with the fact] that my work has withstood this extensive peer-review process.

JK: The results from your original version of your paper are identical to the results reported in this republished version. Why was this republication even necessary? To a layperson, it seems that the new paper is just a restatement of the original.

LL: It was determined that the research needed to be reframed in a way to emphasize that this is a study in which the data was collected from the parents, to expand the discussion about the limitations of parent reports, and to explicitly clarify that “Rapid Onset Gender Dysphoria” is not a clinical diagnosis. Because this paper was of interest to scientists and non-scientists alike, extra care was taken to make sure that certain terms and concepts were not misconstrued by individuals outside of the scientific community. Some of my academic colleagues felt that the amount of oversight applied to my work was above and beyond what it should have been. I felt that my best course of action was to diligently and thoroughly respond, in good faith, to each concern that was raised, which is what I did.

In your own words, how would you describe the central focus of your research?

This research explores, through the reports of parents, a phenomenon whereby teens and young adults who did not exhibit childhood signs of gender issues appeared to suddenly identify as transgender. This new identification seemed to occur in the context of either belonging to a group of friends [in which] multiple—or even all—members became transgender-identified around the same time, or through immersion in social media, or both. The findings of the research support the hypotheses that what I have described could represent a new type of gender dysphoria (referred to as Rapid Onset Gender Dysphoria [or ROGD]); that, for some teens and young adults, their gender dysphoria might represent a maladaptive coping mechanism; and that peer and social influences might contribute to the development of gender dysphoria. More research will need to be done to confirm or refute these hypotheses.

What was the professional background that brought you to this research into gender dysphoria?

I’m a physician who is trained in both obstetrics and gynecology, and in preventive medicine and public health. I spent the first few years of my career delivering babies and providing gynecologic care to women, and I spent the most recent decade of my career involved in public health and reproductive health research. I am currently an Assistant Professor of the Practice in the Department of Behavioral and Social Sciences at the Brown University School of Public Health in Rhode Island. Until recently, I was working as a physician-consultant on a variety of public-health projects mostly related to the health of pregnant women (immunizations, smoking cessation, oral health, premature births) with the Rhode Island Department of Health. I am also a mother, a spouse, a daughter and sister who has been extremely fortunate to have healthy, happy and strong relationships with my family. My core beliefs about the importance of family relationships comprise a central part of who I am. Caring about the health and well-being of individuals and families has been one of the guiding principles of my professional and personal life.

Why did you decide to conduct research in this area?

I became interested in studying gender dysphoria when I observed, in my own community, an unusual pattern whereby teens from the same friend group began announcing transgender identities on social media, one after the other, on a scale that greatly exceeded expected numbers. I searched online and found several narratives of parents describing this type of pattern happening with their teen and young adult kids who had no history of gender dysphoria during their childhoods. I searched numerous websites, and found only three posting these types of parent accounts at that time. Then, I spoke with a clinician who was hearing her clients describe this phenomenon as something happening in their families. The descriptions of multiple friends from the same pre-existing group becoming transgender-identified at the same time were very surprising. Parents reported that, after announcing a transgender identity, the kids became increasingly sullen, withdrawn and hostile toward their families. They also said that the clinicians they saw were only interested in fast-tracking gender-affirmation and transition and were resistant to even evaluating the child’s pre-existing and current mental health issues.

I found these stories compelling and heartbreaking. Gender dysphoria has been studied for a long time, and I recognized that this presentation was not consistent with the existing research. I saw that kids, parents and families were suffering, and I felt that I needed to do something to help. If these descriptions of clinicians refusing to evaluate and treat trauma and mental health issues were true, it means that a vulnerable population was being deprived of much-needed mental-health services. As a physician and researcher trained in public health, I knew I had an important skill set and perspective to bring to the discussion. I felt that the best way that I could contribute was to conduct research to better understand what, where, and why this might be happening.

How did you prepare for this study?

I reviewed the scientific literature about gender dysphoria and peer contagion and I explored the social media environment around gender and transgender identity. Gender dysphoria has been studied for decades, but, until recently, only two types of presentations have been observed. In one type, called early-onset, the symptoms of gender dysphoria begin in childhood. Early-onset gender dysphoria has been documented in both natal males and natal females. In the second type of presentation, called late-onset, the symptoms of gender dysphoria start during or after puberty. Late-onset had only been observed in natal males until quite recently. About seven years ago, the phenomenon of natal females exhibiting late-onset gender dysphoria first started to become visible. This new type of presentation, largely absent from the research literature prior to 2012, seems to be on the rise. Also during the last decade, there has been a dramatic change in the patients presenting to clinics for gender dysphoria—including a striking increase in teens, with a predominance of natal female teens.

I was surprised that no one had yet explored potential contributors to the recent dramatic demographic and clinical changes in adolescents seeking care for gender dysphoria. I believe that when a population seeking care for a condition drastically changes, it is the responsibility of the clinicians and researchers to start asking questions. Why is this change happening? Is the condition in the new population different from the condition in past populations? Without research to explore these questions, we don’t know if the treatments used for previous populations will be helpful or harmful to this new population. In other words, given that these changes are occurring, we should be working to figure out how best to treat this new population. Unfortunately, I’ve heard a few clinicians take the opposite approach—rationalizing these demographic changes in a way to assume the changes are irrelevant and that transition is the treatment regardless. I find this concerning because it seemed that these assumptions were being made in the absence of systematic study. This approach is bound to lead to confirmation bias that can mask clinically relevant phenomena.

What made you think of exploring social contagion and peer influences as factors that might influence teens and young adults to identify as transgender? 

It’s hard not to notice when a condition that was thought to be incredibly rare starts to happen in clusters of people who know each other. Parents online were describing a very unusual pattern of transgender-identification where multiple friends and even entire friend groups became transgender-identified at the same time. I would have been remiss had I not considered social contagion and peer influences as potential factors. It is worth noting that social contagion is not necessarily a bad thing per se. It simply means that behaviors or attitudes can spread through social networks.

When I evaluated the social-media environment, I found that there are many venues where teens can immerse themselves in a very specific narrative surrounding transition. Of course, sites where teens congregate—Tumblr, Reddit, Instagram, YouTube and the like—focus on plenty of themes that are unrelated to gender and identity exploration. But, in the realm of transgender identification, youth have created particularly insular echo chambers. And, although it’s not uncommon for teens to engage with other teens online, I found the content of what was being validated and magnified—distrust of parents and mental health professionals and talking points to shut down the possibility of considering outside views—to be very concerning. The social-media environment seemed conducive to the mechanisms of peer contagion.

As I continued to review the scientific literature on peer contagion, I saw that there were many potential parallels between anorexia nervosa and gender dysphoria. I found the research about friendship cliques setting a level of preoccupation with one’s body, body weight and techniques for weight loss to be compelling, and thought that this might also be applicable to gender dysphoria. The specific group dynamics of mocking “outsiders” and praising “insiders” that has been observed in treatment settings for patients with anorexia seemed consistent with anecdotes I was hearing parents describe about their children’s friend groups regarding transgender-identification.

Where did the term Rapid Onset Gender Dysphoria come from?

I came up with the term Rapid Onset Gender Dysphoria because it seemed descriptive and neutral. The first time I used the term was in the title of my research plan that I submitted to my academic institution. The first time this phrase was used outside of the research application process was on the recruitment information that appeared with a link to the survey on the websites used for initial recruitment. There’s a common misconception that the term Rapid Onset Gender Dysphoria was in use before my study started recruitment.

The term seemed to resonate with parents and they began to use it as well. The term is now used widely. It’s possible that future research on this topic may inform a better name for this phenomenon. The potential pathways of social influence and maladaptive coping mechanisms leading someone to interpret their feelings as gender dysphoria and to seek transition may ultimately be more relevant than the perceived rapidity of the onset. But, for now, I think the term works well.

Some have argued that perhaps youth who seem to exhibit a rapid onset of gender dysphoria had symptoms since early childhood, but it only seemed rapid because the parents just became aware of it. Although that is possible, I don’t think it is likely in these situations. Unlike children typically diagnosed with gender dysphoria, these kids did not, prior to puberty, exhibit any (or only exhibited very few) of the readily observable, hard-to-miss indicators that would need to be present to meet criteria for a diagnosis. For example, it would be hard not to notice if a child had a strong preference or strong rejection of specific toys, games and activities, or a strong preference for playmates of the other gender.

Why have some people criticized your methodology?

Although descriptive studies like mine may [represent] one of the less robust study designs, they play an important role in the scientific literature primarily because they are often a first description of a new condition or population. Some critics have complained about several of the methods used in this study, specifically the use of parent report, targeted recruitment, and online, anonymous surveys. I didn’t invent any of these methods. They are established research methods that have been used in many studies, for many years, and somehow they have managed not to spark this level of outrage until now. Some of the critics of the paper talk about these methods as if they are strictly the province of pseudoscience, but that is simply not the case. I believe these critics are uninformed about the scientific process. In fact, I attended a panel discussion where speakers referred to my study as “methodologically atrocious” and another study—one supportive of social transition—as “phenomenal,” without recognizing the irony that both studies used the same methodology.

Not to put too fine a point on it, but the message of these critics is that research using parent reports, targeted recruitment and online, anonymous surveys is unacceptable for my study, but not at all problematic when used in studies where the findings support their desired narrative. But, that’s not how science works: You can’t judge the strength of a methodology by the results it produces, you must judge the results by the strength of the methodology that produced them.

Are you a conservative or a “radical feminist”? Is your research funded by conservative groups?

Although there have been speculations about my affiliations, I am not a religious or political conservative and I am not a radical feminist. No organizations funded my study. That means that I pay out-of-pocket for research-related costs like printing, traveling to academic conferences, publication fees, etc. And because I do not earn my livelihood providing transition services or referrals for transition, and I have not personally (nor has my spouse or children) experienced gender dysphoria or transition, I have far fewer conflicts of interest than many of the current researchers in this field.

What’s been the response to your research?

The response has been intense, polarized and complicated. Some people express extreme gratitude for this work and others express extreme outrage. There are researchers, clinicians, parents and transgender people who support this research and those who oppose. I was completely floored by the magnitude and the contentiousness of the debate. And I did not expect the pushback to cross the boundary from social media into academic and scientific institutions.

Before publication, I had the opportunity to give talks about my work to three interested audiences that varied in their backgrounds. The most positive response I received was from the largest and most research-oriented audience at the annual conference for the International Academy of Sex Research (IASR). To become a member of this organization, professionals are expected to have published at least three research papers in peer-reviewed journals. After I presented my research, audience members approached me to tell me how important my research is. One very experienced researcher-clinician told me that I should try to present this work at as many psychiatry and psychology grand rounds as I could. Another researcher asked about the status of publication because he expressed that the information needs to be available as soon as possible. There was some lively scientific discussion and some back and forth in the Q & A after the talk, which is not unusual for this type of event.

At another presentation, one that included a mix of clinical and research professionals, several clinicians thanked me for doing this work and shared that they were seeing this type of presentation in their practices and felt that they could not voice their concerns for fear of being called “transphobic.” The scientific discussion was engaging and for the most part respectful. There were some excellent scientific points made by two psychiatrists that resulted in my expanding some sections of the paper to address them. Also, one social worker made several ideologically oriented comments, specifically making assertions about the study’s participants that were not supported by the data. I tried to respond to these points politely and reasonably, but the comments did not influence the preparation of my paper because they did not address the scientific aspects of what I was doing.

The third presentation was the smallest and least research-oriented audience of the three. In contrast to the other presentations, the vast majority of the comments were made by one person who I later learned was a social worker. Again, I tried to answer politely with comments such as “Actually, the scientific literature says the following…”; “Actually, social media can be both a positive and a negative influence, not just positive…”; “Actually, this method of data collection has been used in many studies…” But because her interruptions were so frequent and argumentative in nature, it quickly created a tense and adversarial tone in the room.

Given my experience at these three presentations, I was surprised to find that the Gender Dysphoria Affirmative Working Group, an interdisciplinary group of professionals working in this field, had published the following account of these interactions in December, 2018: “There are many reports that when Littman presented her preliminary results, she was given extensive critique on the poor scientific quality of her research. She made no attempts to address these issues in her final paper, again suggesting she placed ideology over scientific rigor. Some members of Gender Dysphoria Affirmative Working Group personally attended those sessions, and we have spoken to others with the same experience.”

I am not sure what the authors of this collectively authored letter were qualifying as “extensive critique on the poor scientific quality” of the research, since the professionals who were the most highly trained and experienced in research provided the most positive responses to my work. I am aware of the limitations of my study and have described them in the paper, as is the standard for scientific research. And I am somewhat bemused to see that I’ve been characterized as placing “ideology over scientific rigor”—presumably for not parroting ideological points articulated unscientifically.

How did things play out after publication of your original 2018 article?

Within days of publication, there was a blizzard of social-media discussion. Comments came from angry activists, supportive researchers and clinicians, and grateful parents who engaged in civil and not-so-civil online discussions about it. There were tweets that called the research “transphobic,” claimed that it had already been debunked, and called some of the recruitment sites right-wing hate groups. There were response tweets lauding the work as important and imploring PLOS ONE not to cave to activist demands. Some of what was said was accurate, some was not, and some was just plain off the wall. Many of these tweets tagged Brown University and the editor of PLOS ONE. Less than two weeks after publication, PLOS ONE made the announcement that they would follow up on the concerns raised by readers and would seek further assessment, a process that led to this week’s republication. Brown University had published a press release about the paper and then removed the press release from their website five days later, citing PLOS ONE’s decision to reassess the work.

Overall, the reactions seemed to come in waves. First, there was a wave of complaint about the work on social media addressed to academic institutions. Then, there was a wave of support from academics, researchers, and parent groups that included emails, a petition supporting my research that amassed more than 5,000 signatures, and a Quillette article written by the former dean of Harvard Medical School criticizing the institutional responses to the controversy. Next, were discussions about political correctness, censorship, free speech, and academic freedom. And, then there were waves of people who were upset about the previous rounds of responses. There were layers upon layers of arguments. Every day brought a fresh wrinkle. It was surreal.

By email, I received numerous supportive messages from parents and clinicians from several countries expressing their gratitude that I had conducted this research. There were emails from young adults who experienced gender dysphoria, transitioned and then de-transitioned who told me that the paper described their own experiences. And there were emails from individuals who are transgender and happy with their own transitions, but are concerned about the current population of teens seeking transition.

Although the controversy was stressful and often contentious, a lot of good came from it. I believe that my research received far more attention than it would have otherwise. Clinicians who have been seeing this presentation in their practices now had a way to talk about it and to connect with other clinicians; parents who were struggling had a way to reach me; and young adults who had experiences consistent with what I described in my research could also start to find each other. One amazing outcome is that four young women who experienced gender dysphoria in their teens and then de-transitioned or desisted found each other and created The Pique Resilience Project, a video series they use to share their experiences. All of them now speak openly about having experienced ROGD.

The worst outcome for me personally was losing my consulting job over this issue. Shortly after my paper came out, some local clinicians who are opposed to my research wrote a letter of complaint about the work and demanded that I be fired immediately. It was an interesting demand, as my consulting work was unrelated to gender dysphoria. Nonetheless, I was called in to several meetings to answer questions about my research. Some members within the organization expressed concerns that the paper did not support the gender-affirming perspective. The people that I work with most closely had already submitted the paperwork to start the process of my contract renewal for the next year. After the meetings, the leadership explained to me that their decision not to renew my contract was not related to the quality of my work but rather that they, as an agency, needed to remain neutral and not take sides regarding the issues raised in the letter.

I realize now that other academics have received this type of pushback and more. It’s part of a larger issue surrounding the study of gender dysphoria where, if the research findings or opinions are not consistent with a very specific gender narrative, there are efforts to shut down the discussion. Recently, more than 50 academics, mostly from the UK,  wrote a letter published in The Guardian stating: “We are also concerned about the suppression of proper academic analysis and discussion of the social phenomenon of transgenderism, and its multiple causes. Members of our group have experienced campus protests, calls for dismissal in the press, harassment, foiled plots to bring about dismissal, no-platforming, and attempts to censor academic research and publications.” 

Why do you think that there is so much passion surrounding this issue?

Discussion of this topic often serves to challenge many deeply held values. There are parents who are terrified that the steps of transition will be profoundly harmful to their child, especially if done without thoroughly evaluating if there are underlying causes for the child’s dysphoria. There are other parents who are terrified that not taking the steps of transition quickly enough will be profoundly harmful to their child. And despite the certainty that is expressed by advocates for early and immediate transition, the data about what is best for teens whose symptoms begin during adolescence are far from conclusive. Also, there are adults who believe that transitioning saved their lives and wish that they had faced fewer barriers to transition. And, there are adults who feel that they have been harmed by transition and wish that there had been more safeguards in place to protect them. Furthermore, we are a highly polarized society with a tendency to demonize people who don’t share our exact views. It is a perfect storm for heated conflict. I strongly believe that the conversation we should be having around these issues is: some people are helped by transition, some people are harmed by transition, and we need more research to better understand how to maximize benefit and minimize harm. That is exactly the goal of my work.

Will you be doing more research in this area?

Yes. I feel very strongly that this this type of research is urgently needed and that continuing to explore this area is the right thing to do. I am extremely grateful that I have the flexibility to be able to focus my research on what I believe is timely and important.

Featured image: A screen shot from the video “What do DETRANSITIONED WOMEN think of SOCIAL MEDIA?” featured on the YouTube channel “Pique Resilience Project.”