Rapid-Onset Gender Dysphoria: A Primer

Benjamin A. Boyce interviews Dr. Lisa Littman and Sasha Ayad to discuss the phenomenon known as rapid-onset gender dysphoria (ROGD).

This text, transcribed by Donovan Cleckley, comes from Boyce’s YouTube video “Rapid Onset Gender Dysphoria: A Primer,” first published on April 10, 2020, in which Boyce engages in a conversation with Dr. Littman and Ayad. Cleckley has edited the transcript for clarity.

Introduction

BOYCE: Hello, this is Benjamin Boyce, and welcome to my channel. Now, as you might know, I’ve been doing a series on gender, sexuality, and transition, for several months now—actually, for more than a year. And, over that time, I’ve spoken with a wide array of very interesting people, at least, to me, they’re very, very interesting. But one person in this discussion had been evading me.

And then, one day, not too long ago, I was reading an advanced copy of Abigail Shrier’s Irreversible Damage, which comes out on June 30, 2020, but you can preorder it now. It’s very well done. In this book is a chapter devoted to the woman who had been eluding me: Lisa Littman. And, in that chapter, Shrier writes about how Littman hates giving interviews. And I thought that was a perfect thing to tease Littman about. So, I texted her up and teased her about that. She said: “I know, I know. I really don’t like giving interviews.” And I said: “I understand that. I totally understand that.”

But then I had an idea: Why don’t I invite Sasha Ayad and Lisa Littman to have a conversation with me about this topic? What topic you might ask? Well, this is the reason why Littman is so important in the broader discourse. What she saw, some years ago, was a rapid increase in young women identifying as trans or showing up to different gender clinics and talking about how they experienced gender dysphoria.

Up until that point, the research on gender dysphoria was mostly concerned with males. Also, there was another form of gender dysphoria that wasn’t well covered that Littman gave the title rapid-onset gender dysphoria (ROGD), which basically goes to say that the teen doesn’t experience, or doesn’t remember experiencing, gender dysphoria in their early years. It just kind of suddenly happens, and it happens in friendship groups. And it happens kind of in relationship to the internet subculture of gender ideology.

On top of that research, Littman saw that phenomenon, wanted to research it, and, when her research came to light, she received a massive amount of pushback on it, something that was incongruent with anything she had experienced before. And why is that the case? Why is activism restraining the questions that researchers are allowed to ask? Well, that is something we get into. We also get into Littman’s research, and we compare that with Ayad’s practice of counseling teens that are struggling with their gender. So, with much pleasure and without further ado, here’s Sasha Ayad, Lisa Littman, and myself.

Conversation

BOYCE: There’s one issue that you’re both involved in, and that I’ve been kind of researching my way through, is what Littman called rapid-onset gender dysphoria (ROGD). You are the originator of that name, right? And that was in 2016, right? Or was it 2018?

LITTMAN: We started recruiting in 2016. So, probably early 2016 or late 2015 is when I submitted it to the IRB. And then summer of 2016 is when that term was used in the recruitment information that was posted on websites. The first time it was more publicly seen was when the first abstract of interim results was published, and that was March of 2017. And then the paper came out in 2018.

I was searching for a term to use, because I was trying to describe an entity or a scenario. And, as I was writing about it, I felt like I needed something that was shorter than saying “That thing that happens when a teenager doesn’t have a history of gender dysphoria but then starts to develop”—so, I chose rapid-onset gender dysphoria, because it seemed very descriptive and neutral.

BOYCE: What sparked your interest in studying this phenomenon?

LITTMAN: This was not my primary area of research. I’m trained as an OB/GYN, and then I was in private practice for several years. And, then, eventually, I switched over to research with public health, so the way that I see things is very public health-like.

So, I was just observing in my community that one after the next teenager was announcing a transgender identification, often on social media. And it was one after the next. I found this surprising, given what I knew about the expected prevalence of this was, and I found it surprising that these kids who were making announcements were from the same friend group. That was the initial thing that sparked my interest.

From there, I went to do a little bit of background research on my own. I looked through the literature about gender dysphoria and gender dysphoria in children and adolescents and adults. And I did not see any theories about or any documentation of these clusters of friendship groups. So, I thought: Okay, this is unusual. And then I went, and I looked online. I saw some narratives of parents writing about their kids who didn’t have any symptoms of gender dysphoria as a kid. Many of them went through puberty, and then, on the other side, they belonged to these friend groups where they talked a lot about this all the time. And then multiple kids made announcements and identified as transgender.

What I saw in these narratives, a lot of things that were surprising to me, is that the parents described, one, that the kids seemed to get worse the more that they announced or took steps; they became really somewhat distrustful of or hostile toward their parents. The other thing is that the parents took their kids to the doctors and took their kids to the therapists, and they described that the therapists really weren’t interested in hearing anything about the fact that the kid had a mental health history or issues or ongoing symptoms; or, that they were the fifth, sixth, or seventh in their friendship group to come out that year; or, that the kid had experienced rape recently and that this only came right after. And they described how the clinicians basically said that the only answer is to get on board with transition and otherwise you’re transphobic.

These very basic concerns about Is this the right diagnosis? Is this the right path? Is this the right thing to do?—were really brushed off. It just seemed so odd to me, as a physician and as a researcher, why anybody would completely not be interested in a kid’s history and what their symptoms were and what their social situation was.

I went online, and I looked at what the kids were posting on social media. I did a deep dive into Tumblr. So, I saw a whole new world of teenagers giving advice to other teenagers and giving them validation for certain things that shouldn’t be validated and giving them grief about things that maybe they shouldn’t give grief about. I saw a really interesting world there, around this topic, where it was very black and white: They were really dismissive of kids who weren’t trans and very praising of kids who were.

Those four things are what led me to decide to study this and to basically look at this as research. This is a scenario or a situation that doesn’t seem to have occurred previously; let’s find out about it.

BOYCE: Were there any similarities that you saw between this phenomenon and other phenomena? Was there anything that you’re relying on to get guidance on these clusters of individuals of this age group coming together around a certain specific problem? Or was this really very unique?

LITTMAN: It seemed to me that it sounded like the scenarios around eating disorders, because that’s something that’s been observed, too: Having friends with eating disorders kind of increases the risk. There have been observations from in-patient and out-patient treatment groups that have had unintended consequences. Instead of resulting in this sort of improvement, there would be cliques that formed in which those who were the most thin and the most ill were revered as the superstars and admired. And, then, those who weren’t as underweight were seen as outsiders. It did remind me of that, that there’s sort of a social aspect to it.

The other thing that’s been observed in in-patient and out-patient eating disorder treatments is that sometimes the more experienced patients with eating disorders would teach the tricks to the younger ones. Things such as using laxatives. How you can do things to make your parents think that you actually ate something that day. Ways to make it appear like you haven’t lost weight even when you have. It seemed very parallel to me to the advice on these social media about: Here’s what you should say to your doctor so that you can get hormones. Here’s how nobody else understands you and how your parents are really the enemy. It just had that kind of a feel to it. And I feel like it would have been irresponsible not to explore that.

BOYCE: Did you use the scientific literature on eating disorders to help guide structuring your research? Or where did you have to go out on your own limbs?

LITTMAN: I definitely relied on literature around gender dysphoria. There had been a study that had come out of, I think, Finland. They had described that, after the first two years of a new treatment center for gender dysphoria, there was a small subset of kids that had significant mental health issues, neurodevelopmental issues, and had no childhood gender dysphoria. There was some literature there that informed the research.

Yes, the research about eating disorders did inform sort of how I created the survey, for some of it. But most of it was really sort of this big view of what is going on. I had a section of describing things about the kid’s childhood, things about the child’s gender dysphoria symptoms, things about the kid’s social scenario, their online habits, what happened after, what they asked for about the relationship. Really, I wanted just this big view of what’s going on here.

When I started, I didn’t know whether there’d be ten people or a hundred people or five hundred people. Because, when I first started looking, there were only a couple of narratives that I found, so I didn’t know how widespread this scenario might be. During the period of time that I wrote my survey, started launching recruitment, and then the long period of time it took me to write the study, it just seemed like it was happening more and more.

BOYCE: Was there any resistance before you published? Were you just on your own? Was there any pushback?

LITTMAN: In the beginning, there really was not, because, again, I was taking this very scientific approach to what is happening. I really did not expect this to be as politicized. My previous area of research was abortion, so that’s kind of controversial. This did not seem like it would be significantly more controversial than that. But, during the course of the time that I was working on things, I went to a WPATH [World Professional Association for Transgender Health] conference, and that came across as very political, very one-sided, at least the sessions that I saw.

The first real pushback that I saw was when the abstract was published. I presented the interim results at a conference and I got mixed reviews: Some people were like: Thank you. I’m seeing this. I’m glad you’re doing this. Other people were like: Woah. This is not acceptable.

I guess the first documented thing was I think there were some articles written after the abstract came out. Some folks saw it and were very ready to write about how this couldn’t possibly be true, couldn’t possibly happen, before the paper was out. It was fascinating to me. What was published was a very short, little abstract. A paper has pages about what the methodology is and pages of an introduction. And I thought it was fascinating that people were writing these full blogs about the methodology and how this couldn’t happen, without having read the paper, because the paper didn’t exist yet. But they were ready to go.

I think that was the first little inkling. I don’t know if the world was changing or if I was naive, but I was expecting, after my paper came out, that there would be some buzz on social media and that would be it. I didn’t think that the buzz would translate to academic institutions or journals or editors or anything like that. I still believed that social media was its discrete, little place, and then there was real life, and then there were academic institutions.

What I was surprised about was how seamlessly the passionate response that happened on social media immediately went over to the journal editors, to the university, to everywhere. That was really surprising to me.

BOYCE: You were more or less censured? Did they go after your job and your other positions that you held that had nothing to do with this particular paper?

LITTMAN: I wouldn’t say I was censured. I did have a consulting job, and so individuals went to the directors of my consulting job. And my consulting job, by the way, had nothing to do with gender dysphoria. I was a physician consultant. I was going out to OB/GYN offices and talking about what kind of programs we have to help pregnant ladies stop smoking or things like that. So, it was really unrelated to this. But there were people who wrote a letter saying: We are very upset about this paper, we think it’s going to do bad things, we don’t like the methodology. I think they misrepresented a lot of what was actually in the paper or what my presentations were, but, in any case, they wrote this letter to the directors saying: We demand that you fire her, immediately.

What happened, then, I think, was also surprising, given that this was not part of my job there. But I was called in to talk about my research and to explain my research and to talk about my intentions, which are, basically, to understand what is going on so that we have a better idea of this process. They felt that they needed to take a neutral position. That, if they fired me immediately, that would be taking the side of the letter writers, but, if they rehired me for another year, that would be taking my side. So, when my contract came to an end, they chose not to renew it. I have to say that the people that I did work with directly had already submitted all the paperwork to renew my contract for the next year, so I can feel pretty confident that this decision not to renew was actually part of this, from the paper.

BOYCE: How did that shift your thinking about this process? It seems like you were just kind of going down and investigating something and then, all of a sudden, you had this huge reaction. How did that shift your thinking about this issue?

LITTMAN: I thought that, given the response, that it was really important to get to the bottom. It just felt like maybe I hit a nerve, but there’s this whole experience and there’s this whole different development, progression, experience that people are having. Why is there a group that really doesn’t want to hear it?

I just feel, as a scientist, as a responsible person, that, despite the noise, I have to go where the truth is. It felt like there would be more harm not doing it, because I could hear that this was happening; I was hearing from clinicians who were seeing these kids. Some people contacted me after who were clinicians and said: Thank you. I’m seeing this in my practice; it doesn’t make sense. I don’t know what to do. I’m glad that you’re doing that. So, really, I felt, despite all of the noise, between that and between hearing from detransitioners who were saying: This was my experience. I wish people had taken time to figure out what was going on with me before rushing me down this track. I was getting a lot of different messages, but the end of the story was this is important and this is worth doing.

And I’m just grateful that I can do this. There are people who are in this position who might have a relative going through this, so they can’t be public about it. Or, they’re trying to get tenure somewhere, and they have to worry about how it’s going to be seen or affect that. Being in the place that I am, I just feel motivated that this is important information.

BOYCE: I’ve seen, at least on Twitter, that your first study comes up, and then people say that it was “debunked.” Could you explain what happened with that? Was it retracted and then exonerated? Could you explain what happened with the first study? 

LITTMAN: Sure. Well, the first thing is that I think there are a lot of people who are using scientific words not exactly correctly. For something to be debunked, it’s something that you would need to prove wrong. So, that’s not what happened. What did happen is the paper came out, and I think the journal was bombarded with a lot of people talking about it, some people complaining about it, some people praising it. So, they felt it was necessary to do a post-publication review, which, it happens. It doesn’t happen all the time.

The paper had already gone through the basic steps of review, that a couple of reviewers had read it, provided comments, I responded to them; then, an academic editor read that, gave some more comments, I responded to those, and then it got published. 

They did more review; they had more people coming on and giving comments and then I responded to them. The paper was available up until the time that the revised paper came out. I think there’s been a lot of discussion about methodology and things like that. Some people did not like the methodology that was used, but I didn’t invent any of the methods that were used in that paper. These were pretty standard methods that are used.

BOYCE: Could you explain the methods?

LITTMAN: Well, there are a couple of things. It’s collecting the data by parent report, it’s a cross-sectional survey, and it’s an anonymous survey. There are different parts of it. I think what’s happened is that some folks are playing a little fast and loose with the rules.

Scientifically speaking, you don’t change the rules based on whether or not you like the findings. Parent report is something that is used quite a lot, and there’s a whole literature of research in which children and adolescent physical and mental health information is obtained through the parents. Again, there are strengths and weaknesses to this, as you would imagine, but it is not out of the ordinary. In fact, one of the main research papers used to support the social transitioning of young children is a parent report study. So, I felt it was important to kind of link together where the methods that I used are also used in the studies that are frequently cited to support social and medical transition.

Parent report is one aspect. And, then, there’s a convenience sample. In studies, there are different kinds of samples you can get. You can get a clinical sample, where, if you’ve got a clinic, you basically enroll everybody who’s eligible who is seen during a certain period of time. That’s one way to do it. A convenience sample is where you reach out to different areas and you try to find people to take part in the study. For mine, I reached out to websites where I had seen parents reporting this type of thing. I know another study where they reached out to gender-affirming camps and conferences and things like that. So, there’s always a risk of selection bias in any of this, but, again, it’s sort of across the board. You can’t say: This is acceptable here, but it’s not acceptable here.

Anonymous studies are often used, because, especially for topics that are stigmatizing, it allows people to be more honest. But a downside is that you can’t verify the people who are taking it. Again, there are a lot of anonymous studies, some that are used in transgender health and a lot of different areas. I do think that some of the attacks on the methods were a little bit…I’m trying to look for the right word…[BOYCE: “Okay for me and not for thee kind of thing”?] Yeah, yeah.

Admittedly, it’s for a descriptive study, so this is not the end-all, be-all, last study on this. This was meant to be the first description, that these hypotheses will be tested later. Given where it is, it is not that dissimilar to others of that type. That’s sort of in a nutshell.

BOYCE: Sasha, from your perspective, how has that study affected your view or your work, working with individuals who would, some of them, fit under ROGD and some of them not?

AYAD: I’d like to start by saying that one of the things that make this study valuable is that it is very broad. The questions in the survey really assess lots of different areas of functioning, both long-term, like in early childhood, all the way up until the trans declaration. That’s really the power of the study, that there isn’t really a narrow hypothesis. Of course, we do see this clustering in friend groups. That’s one question that emerges from this study.

What makes this study very helpful is that there are all these other factors taken into consideration such as giftedness, such as autism, such as trauma and mental health issues. I know that, as a clinician, those are themes that I see that end up emerging in the kids who develop dysphoria in adolescence. 

First of all, it’s given adults and parents and kids another conception for what might be going on. Because what would happen oftentimes is, and even with the children themselves, is that there is this one narrative that existed prior to the early 2010s about dysphoria really having been this lifelong experience, that would have been very obvious to anybody around. The nature of dysphoria, insisting that you’re the opposite gender and believing that you’re the opposite gender, is something that you couldn’t really hide, unless you had this meta-awareness even as a small child. A lot of young people whom I work with now are able to say—I’ve heard kids say: I want to make sure I don’t have ROGD, because, when I was young, I didn’t really have dysphoria. And so, both parents and young dysphoric people now have another way of trying to understand: What is this current experience that’s playing out in our families?

For many young kids, there was a narrative put forth by a lot of the affirmative clinicians, affirmative YouTubers, that said: Even if you didn’t have dysphoria as a kid, it doesn’t mean you’re any less trans. So, a lot of young people were digging in their childhoods and trying to figure out: Was I dysphoric? Or was I not dysphoric? But we now have this ability to say that there might be this other presentation of gender dysphoria that we don’t know much about, that we don’t quite understand yet. And it’s not necessarily meant to just completely dismiss whether or not transition is a good idea for somebody. But it does give us another way of looking at what’s happening, to try and understand: What can I use to describe my dysphoria? For me, that’s really the application of the study. We have more questions now, of course. But this is really, really important, because everybody knows this is happening.

I talk to young people all the time, who are dysphoric, who identify as trans, who say: I see all these younger kids just claiming to be trans out of the blue or becoming dysphoric out of the blue. So, even young people who maybe believe that they should transition and identify as trans recognize that this phenomenon is happening.

BOYCE: What are some of the next questions that developed out of this first study? How does that change the investigation?

LITTMAN: The next set of questions is what types of actions/experiences might be related to the start of somebody feeling gender dysphoric, and, as we are seeing people who are detransitioning, what types of factors are associated with the resolution of these feelings. Those are a lot of different questions. We don’t know how common this is, what is the best course of action for these young people; these are things that need to be explored further.

What we do know is that there’s been this massive change in young people presenting for care for gender dysphoria. In the past ten to fifteen years, there’s been this enormous rise. And there’s been a change, in that there are now a lot of teenagers and really a lot more natal females. It used to be predominantly natal males and now it’s predominantly natal females.

What is also very intriguing is that, prior to 2012, it was understood that males could present with gender dysphoria either as young children or as teenagers or middle-aged men. At that point, there was almost nothing in the literature about natal females having an absence of gender dysphoria prior to adolescence. In some of the literature that I’ve read, it says that, when natal females presented to a clinic with their families, there were gender-nonconforming behaviors occurring from childhood that were remembered by the child and by the parent.

Right now, what we’re seeing is very different. We’re seeing scenarios where, perhaps a child remembers a history and a parent doesn’t, or neither of them remember a history. So, that’s very new. And I think we have to ask why. What is this new presentation? And is it the same as the other ones? Is it going to respond the same way to treatment? Or is this something that’s going to be temporary? Because, if the gender dysphoria is going to be temporary, then weighing the risks and benefits is way different if you’re expecting the gender dysphoria to be something that lasts six months, a year, or the rest of your life.

I do feel that the first paper just opened up a lot of questions that can be asked.

BOYCE: Are there other studies that you know of other researchers, that you’re aware of, taking up exploring different facets of this alongside you out there in the open?

LITTMAN: There’s been a lot of research about the different typologies of gender dysphoria: the early onset, in childhood, the late onset for males. Researchers and clinicians are recognizing that late onset in natal females is a new thing. 

I have seen some literature describing a more exploratory study with teenagers, especially those that have complicated mental health histories, sort of a gender-exploratory model, in which the big picture of mental health and these other issues are explored, as well as exploring with the kid what does it mean to them. For some of the cases that have been described, the gender dysphoria resolves when the mental health issues have been addressed. There has been some research, or at least case reports, let’s say, around that area. The next stage around this is case reports getting published, where clinicians can document what their experiences are.

I do have a second paper that I’m writing about detransitioners. So, some of these themes come up again, and the benefit of having the detransitioner research is that it’s first person. These are not parents talking about their children; these are adults, eighteen to sixty plus years old, talking about their own experiences. Many of these things came up, things like a history of sexual assault, things like mental health issues and trauma being the cause of the feelings that made them think they were transgender. There are also some narratives around people transitioning or identifying as transgender, because they had a very difficult time accepting themselves as lesbian or gay. Homophobia is something that definitely needs to be explored, especially toward lesbians, especially young lesbians. That a lot of the feelings of feeling wrong—there is something wrong with my body, there is something wrong with me—may be related to this homophobia. Those are things that are emerging from the detransition work.

There’s also the narrative that we hear that some people are happier when they transition and then they detransition because they faced discrimination, phobia, or pressure from people in their lives. So, there’s that narrative as well. I think what’s going to come out of the detransition work is that there are a lot of experiences that may contribute to somebody feeling gender dysphoric or identifying as trans or seeking transition. There are also a lot of reasons why people may detransition, whether it’s because their mental health got worse when they transitioned, or because it got better, but they had pressure from people in their family, or needing to have a job, for example, or a medical problem that meant that they had to stop. That’ll bring up some more questions.

BOYCE: Do you have faith in this line of inquiry kind of breaking down that tight narrative structure that you ran against when you published your paper? Do you have faith in the establishment or the process of refining this and making things a little bit more open to nuance, for lack of a better word, in this form of care?

LITTMAN: I think the audience for these papers, both the audience in terms of clinicians and researchers and the audience in terms of people who are interested, there’s not just one view there either. It can be polarized, and there are multiple views. There may be some pushback, but I think there will also be, in the same way, some support of this narrative explains x, y, and z, so let’s just make sure that it’s out there. So, I guess I do have faith in the system, that continuing to research and write papers is the way to go.

BOYCE: Is there a way to constellate you two in theory and practice and how those two things fit into each other? Would you be able to give me some insight into how somebody in Lisa’s position and somebody in Sasha’s position, how your work kind of overlaps and feeds into one another?

AYAD: For me, as a clinician, I try to use this approach of being radically open to seeing what the case studies will say. When I’m working with clients, I try really hard not to have a hypothesis in my mind. Now, as a clinician, part of your job is to figure out what’s going on with people. But I try to stay really open.

I’ve talked sometimes in my videos about how, when I started this work, I wasn’t really sure what I was going to find. And now that I’m working with this population, a lot of new insights have come about. So, for example, there seems to be a link between eating disorders and gender dysphoria. This is not something I had any idea about when I started doing this work five years ago. That might be an area of inquiry that would be good for researchers to pick up, because it seems to be part of the phenomenon. And that’s why it is important, whether you’re a researcher or a clinician, to just stay open and allow your clinical work or your surveys and your data to actually lead your area of inquiry. That is an example of how, as a clinician, I might say: You know, Lisa, this is something I’m noticing in a lot of the kids that I work with or a lot of the consultations that I’m doing. What have you found? And, then, that might be a question that researchers can pick up and ask more about. 

LITTMAN: Yeah. I definitely think that the communication between clinician and researcher, and there are people who do both, is really important. Because, when Sasha raises issues and talks about what she’s seeing, then that may change the way that I might ask a question in the next survey. I feel like I’m learning all of the time from listening to clinicians and what they’re hearing and what they’re experiencing in their practices and also when people reach out to me. So, that informs some questions that I might ask in the study.

BOYCE: And are there forums where people in your two areas get to meet and mingle and overlap? Or, is it just emerging and you just find the literature and then you reach out to one another individually?

AYAD: Well, it seems like a lot of clinicians are finding ways to connect with each other. I know Lisa and I, of course, have been in contact and working together for some time. Because this is kind of a controversial area, though, it has become a little bit challenging to have good faith inquiry and just posing questions. It seems like, whether it’s online communities or even maybe in professional organizations, if you do not adhere to a very narrow perspective on these topics, it can be very hard to find honest comradery or inquiry. Sometimes it’s challenging, but I think that, for those of us who really with good faith just want to understand what’s going on without necessarily a very hard stance on things either way, I think we end up finding each other and end up working together.

LITTMAN: Yeah. I would agree with that.

BOYCE: Where are we going now? We’re looking into more instances of detransition, looking into various different methods of providing questions for the gender dysphoric youth to map out their own lives. Is there any big thing on the horizon that’s going to open up?

LITTMAN: I think it’s more of a slow process. I don’t see any big, conclusive study. As individuals who have detransitioned are more vocal and talk about their experiences, I think that’s going to be one way that there’s going to be more nuance to the discussion. As clinicians are starting to find each other who are interested in this big picture of how there may be many ways, not just one narrative where a person seeks transition, gets transition, and life is better. The clinicians are like: Oh, I’m seeing a lot of different kinds of patients come in, with a range of issues and a range of outcomes. So, I think as they start talking about their experiences, there’s going to be more nuance and then the research.

I don’t think it’s going to be a painless process; I do think that, because people are very passionate about this, with good reason, there are people who feel that the interjection of new narratives might disqualify their own experiences. There are parents who are worried that their children are going to be treated and then be harmed by that treatment. And, there are other parents who feel that their kids are going to be helped by treatment and then not be able to get that treatment. It’s going to be a very passionate process, a little bit at a time, really a methodical way of exploring, taking in more information, and exploring again. That’s my thought.

AYAD: On the clinical side, I can share that, for me, it’s really interesting to find that, the more young people are identifying as trans, the less value the trans identity seems to have for some kids. A lot of times, when you look at conditions that have spread through social contagion, at the historical documentation of these types of things, when a diagnosis loses its potency to communicate something important, that’s when it starts to kind of fizzle out. It’s interesting to see, at least in my case, some kids will say things like: When a lot of other people are identifying as trans, it makes me angry, because it doesn’t mean anything that I am trans.

From the clinical perspective, I don’t know how all of that is going to unfold, but there is something really interesting, when you notice this humongous spike; the meaning behind what it is to be trans or to have gender dysphoria inevitably changes. Because now it’s much, much more common and it encompasses a broader range of types of people who have it. That’s something interesting, too, so I’m really curious about what that is going to mean. And I don’t know if that’s something that we necessarily can study with research, but it’s something that is unfolding and I’m really interested in it.

BOYCE: One thing I’ve noticed is that, at least with that one statistic, there’s a massive increase in females seeking gender therapy. What are some of the things that this might help us better understand about female health, female psychology, and female sexuality?

LITTMAN: I think it’s true now, as it’s been true for a very long time, that it’s very difficult to be an adolescent female. There are, I think, right now, so many factors, so many influences going on, so I do think that, for some, this could be a response to all of those stressors. The literature shows that social influence does happen more with females. And I see that, not as a weakness of females; I see that as a strength, actually; the being connected to other people, I think, is a strength. Just, in taking sort of the long view, to me, it seems like the glue to society is how women make friendships with other women. I just really think that’s a very valuable and important part of being human and having a society. So, I don’t see that as a weakness; I see that sort of empathy and interaction as a strength. That said, again, it’s not completely women; there are males who are very empathetic, and there are women who are not. But I do think that’s one piece of the puzzle.

With the female body, there are things that are great, and there are things that are really not great, so I completely empathize with the desire or need to either avoid or escape some things. So, it’s complicated. My background, as an OB/GYN, was very sex-based; my patients were female. And the processes were things about preventing unintended pregnancy or helping people get pregnant or helping to manage a pregnancy and deliver a baby. It doesn’t get more sex-based than that. I think coming with that perspective it’s a little bit unique. But I definitely feel this understanding of why this would hit females quite a lot.

I think this is a different way to express distress, which didn’t exist ten, fifteen years ago. When people are in distress, they’re looking for ways to feel better. That’s human nature. And so, this is a narrative that I think may be comforting to some people, especially as the other options may be scarier to them. Whether someone really does not want to be female, because they experienced a rape. I could see that, sitting in a traumatic place, one would want to really distance the self from anything female.

For males and females who might be experiencing some other kinds of trauma or very scary mental health issues, young adulthood is when some of the more severe psychiatric illnesses sometimes take hold. And those can be very, very scary. So, this might be an explanation for that. There’s just a lot of different narratives. And, then, also the escape of not wanting to be lesbian. I feel like we’ve grown so much in terms of tolerance as a society, but, definitely, there seems to be a pecking order in certain groups. Lesbians are just seeing a lot of negativity coming their way. I just think the world is just more complicated than there is one answer for everybody. This is something that you want to come to the right answers for the right person.

AYAD: Lisa, something you said is really ringing a bell with me, because you talked about just all of the reasons that a female person may want to escape their femaleness. A trait that I see as really common in both males and females that have ROGD is a high level of sensitivity to the outside world—a really strong sense of what other people around me expect or what other people want me to be, a lot of highly perfectionistic kids. And so, there’s something about that, too. Like you said, this is not a weakness of women; it’s a strength. Well, this sensitivity to the world around you is very, very powerful, and, if you haven’t yet developed a really strong sense of yourself; if you have not been able to cope with the fact that you might disappoint people sometimes; in just pursuing your own truth or what feels authentic for you, it can be very easy to be swayed, and you might turn against yourself, or you might really play the role that everyone around wants you to play. This is a very common thing I hear: Kids who don’t want to disappoint anyone in their lives ever.

It’s interesting, because there is this narrative, sometimes, on the far right, that trans-identified kids are just doing it to be “special,” but I actually find it to be quite the opposite; a lot of them are trying to run away from themselves and hide behind a different persona. That sensitivity, I think, plays a really big role there.

LITTMAN: Yeah. That’s really interesting. Ten years ago, twenty years ago, you might be worried about the thoughts and opinions of people in your circle, but, now, with social media, your circle is like thousands and thousands of people, that people spend a lot of time on. So, there are so many more ways to be worried about disappointing.

BOYCE: And finding alternative forms of comfort.

LITTMAN: Because part of adolescence is really trying to figure yourself out and figuring out who you are; that’s just normal, healthy development. I see this as a little bit of a perfect storm, that there’s just a lot going on; there’s a lot of stress in society, there’s a lot going on on social media.

This is the age where kids generally are sort of stepping out and trying to learn about themselves. For some of them, this might be the right direction, but I think for some of them this might not be the right direction and might actually derail them from where they’re ultimately hoping to be.

AYAD: What I wish we had more space for is: Can we contain that type of exploration in more of a symbolic way? That’s really what’s missing. Because, even if somebody feels like exploring a trans identity is something that’s valuable for them at the time, why isn’t there space for that without having to abandon your old self and throw away all of your childhood memories and photo albums?

There is this complete shedding that I see a lot of times of the old version of yourself, rather than creating a space where maybe this is like a part of your path that you’re going to walk down to learn something new about yourself or tap into like a more confident version of yourself. But it doesn’t have to be marked with such an alienation from your old self. Now, some of that is pretty typical in adolescence, but the fact that this is often coupled with medical intervention, which, of course, concretizes it and makes it permanent, that’s really the part, to me, that’s very troubling. Because, what we know about adolescence, like you said Lisa, is that this is part of a healthy development, sometimes, to explore different versions of identity, or question who you are and what group you fit into. But, then, putting that in a medical intervention seems really premature.

BOYCE: Yeah, Lisa, what are your thoughts about the medicalization of this issue? And do you see that there needs to be some activism with regard to the medical establishment to change some of the ways it’s been overcompensating in the direction of affirmation?

LITTMAN: I think part of the problem is that there has been activism in medicine. The professional organizations tend to be very focused on being evidence-based. I think there are a lot of disconnects in terms of the research and the certainty that people are saying that affirmation and medical treatment are the only answer. So, that’s been a little surprising to me, that it’s been really framed as “This is the kind, this is the positive way.”

There’s been some, maybe, overreach in terms of claiming some of these treatments as “evidence-based.” For example, if you look at the Endocrine Society guidelines, the most recent ones, they grade how strong the evidence is for each of their recommendations. For the treatment of adolescents with puberty blockers, with hormones, the grade of the evidence is “poor” and “very poor.” And I think that’s an honest, open way to discuss it, because you really couldn’t do a randomized trial of this topic, but there’s a lot of loss to follow-up in these studies or the study populations are just very narrow that may not be generalizable.

So, given that the evidence to support medical treatment for adolescents is “low quality” and “very low quality” evidence, to have organizations come around and say, “Well, this is evidence-based,” I feel like that’s a little bit disingenuous, or maybe there’s a disconnect somewhere. Again, I’m an optimist; I do think this is going to balance out, as the discussions become more broad and more nuanced. But I do think that confirmation bias is a real problem, in that, as human beings, we all want to be confirmed in the research that we see, seeking out research that actually is consistent with the findings that we want to be true. And I think that’s been going on for some time here, as more comes out; that’s one of the ways that things have been medicalized a little bit, I think, faster than they really should have been. 

AYAD: I think this also really highlights for us how little we know about gender dysphoria as a condition. First of all, we have seen that it can increase in astronomical numbers, so that’s something. And, we have seen that the medical treatment, that has been the standard for decades, does not help many, many people, as we see with detransitioners.

So, this also is forcing us, as a medical industry, as a mental health community, to stop and say: Okay, maybe we need to try and understand this in a way that is not purely medical. Because there are a lot of psychological aspects of this that, for some reason, based on the Harry Benjamin method, have just been discarded, without really giving it a shot at trying to help people in a compassionate way, in a way that is not homophobic or is not going to demonize a cross-sex exploration or identity. There are so many ways that we have not asked questions about gender dysphoria and have not tried to support people who have it, that I think this huge, massive exodus of detransitioners is going to force us to ask those types of questions. And, to me, as a clinician, that is what I find really interesting about my work, because I have seen how a slow, compassionate, careful approach does help a lot of people resolve their dysphoria in other ways.

BOYCE: Are there incentives not to get it wrong? Or, are those incentives missing when activism comes into the medical field? How do these communities correct their overreach?

LITTMAN: I think that one of the things that’s going to be helpful is having these different perspectives being published. What I’ve heard is that there are many clinicians who facilitate transition who say: “Oh, none of my patients detransition; I’ve never seen anybody detransition.” On the other hand, what we hear from detransitioners is that they don’t want to go back to the physicians who facilitated their transitions. So, I think that disconnect kind of keeps us in our separate silos. If there is more discussion of this, it might inspire maybe better follow-up in terms of clinicians maybe thinking about their lost to follow-up patients not as all having moved and are doing great and found another provider; but sort of thinking that maybe this doesn’t work for everybody.

And, perhaps, this is my hope, that, maybe on the front end, with this broader understanding of transition, they might say: I want to know however this turns out for you. So, if this doesn’t work out for you, please let me know, because that will help me understand this process better and then I can incorporate that for the next patient I see. And I wonder if detransitioners aren’t getting that message, that they get a message that maybe the clinicians don’t want to hear from them. That sort of conversation may inform the process.

BOYCE: I can see clinicians having facilitated someone going down a permanent medical path, who then doesn’t enjoy ending up there; I can see why clinicians wouldn’t want to see those cases or why it would be a nick on their own egos.

LITTMAN: The pushback against hearing about detransitioners. It takes so much bravery for them to even talk about it, because, on social media, they get a lot of grief pointed their way. But, if you think about it, back from the medical model, if you’re working on any kind of intervention, why wouldn’t you want to know about all of the outcomes. In my mind, I always go back to OB/GYN stuff. Let’s say there’s a new technique for a cesarean section; you wouldn’t say: “This works great for everybody. I only want to hear about the good outcomes.” No, you need to know about all of the outcomes, because that informs how you go forward. Let’s say 25% have good outcomes; that’s a different story than 75% having good outcomes. But, if you don’t know the whole story, then how can you really have confidence in your intervention? 

BOYCE: Is there a precedent for the medical establishment having pushback when they explore these difficult questions?

LITTMAN: Well, there is a long history of clinicians and patients getting very excited about an intervention and then going forward really quickly, before the full benefits and risks are known, and then have it be tempered back.

When I was a resident, in OB/GYN, the literature at that time, the recommendations were any post-menopausal woman was offered hormone replacement therapy, because this was viewed as preventive. This was going to not only prevent osteoporosis but prevent heart disease and things like that. My first couple of years in practice, more research came out that showed some negative outcomes, and then the whole specialty changed. It basically said: Oh, no. We need to view this as a medication, not a vitamin; there are risks, there are benefits. We have to tailor it. And that’s an example when it goes well, because I think it was a very short amount of time where things changed rapidly.

But, if you think about the opioid crisis. Years ago, opioids—they were great for short-term pain relief, for surgery, for all these things, used very, very commonly: “Is there a risk for dependence, for abuse?” And I think there was a little bit of a delay before people were willing to consider that. That got farther and farther along before we were able to pull it back. Right now, it’s different. At some point, there was this discussion about whether we should be asking people about pain levels and things like that.

So, yes, I think there has been this sort of back and forth that happens. In this case, I do think that the activist arm and the framing has made it harder for us to really comprehend that there are risks also and that we need to temper about and think about: Is this the right treatment for the right person? With post-menopausal hormone replacement, where the turnaround was kind of quick, for opioid use or even let’s just say the over-prescription of antibiotics, maybe a little bit longer. But I think that this pushback and this single-minded approach are going to make it take longer before we can get back to that place where we can look at the patient more holistically, look at the treatments more holistically, and to individualize that way.

AYAD: So, Lisa, you’re lifting up the tendency of the medical establishment to sometimes latch on to what is seen as like a “miracle cure” at the time, usually this new kind of development. But I think another layer that makes this even more complicated is that there’s this kind of dual perspective that is placed on a gender dysphoric child.

On the one hand, the activists have really tried to frame transgender children as a similar thing to being gay. As a therapist, in all of these workshops and continuing education classes, it’s often “LGBTQ,” “LGBTQ,” as though all of those are just another version of some kind of sexuality that someone just has and we have to support.

There’s a trans woman named Corinna Cohn, who’s talked about these issues. I just pulled up her tweet, and she said: “If you believe there are ‘trans kids,’ you will seek different solutions than if you believe there are children who suffer from gender dysphoria.” That is, I think, in a nutshell, one of the most powerful concepts that people have to understand. That’s why clinicians and doctors are very hesitant to ask: Is this treatment effective? Because even asking the question implies that there is something wrong with this transgender child. But, if we can kind of pull back and ask about this thing that this child is suffering with, it’s very different than just rubber-stamping that this is a transgender child and this is a life-saving intervention.

LITTMAN: I agree with that 100%, because I do think it’s premature to call a child transgender. What the literature shows is that most of the children who feel gender dysphoric as children, when they get through adolescence, and often will figure themselves out and go through certain pubertal milestones, will identify not as transgender but often as gay or lesbian. So, gender dysphoria might be about someone going to be gay, lesbian, or bi. There’s really no way to tell, in real time, during childhood; you don’t know the trajectory of the child. To basically place the label of trans on them, it adds this solidity and this certainty when we don’t know.

There have been a lot of terrible things done to gay, lesbian, and bi people, and to trans people, and I think maybe there’s this understanding like: Oh, well, we don’t want to do that, again. Clearly, nobody wants to do that, again. But we have to basically make sure that we’re not pushing a child in a certain direction, when that’s not the direction where they would have gone, just because this is how it might have been explained politically. I do appreciate that caution. We don’t know yet, and maybe we shouldn’t be viewing medical treatment as the only way to go at an early age, when we think about young children, not that they’re getting medical treatment, but as that’s going to be their course.

AYAD: Yeah. And I wonder, too, if part of the reason that society at large has been so quick to adopt this narrative of “the transgender child” maybe also has to do with just wanting to sanitize and to wrap up this gender dysphoria in a way that feels palatable and positive like an identity. Because, if you think about the nature of what gender dysphoria really means, it’s a person who feels such an excruciating disconnect from their own body that they want to change it, even very young. If we were to just stop and think about how distressing that probably feels, that’s not pleasant; I don’t think anyone wants to sit with that. So, instead, we’ve repackaged it like: “Oh, it’s a trans kid! Yay!” And there are all of these really positive media stories about it.

I imagine that, for adults in the medical community and the mental health community, that probably feels a lot more positive and a lot less distressing to really sit there and think about: What is the suffering of gender dysphoria? I know a lot of activists say: “No, it’s only because of discrimination that people suffer.” But that’s disingenuous, too, because, by definition, gender dysphoria is a disconnect with your own reality, so that is painful. I’m just curious about that, on a broader level: Are we all just having a hard time really grappling with the fact that we’re seeing massive numbers of young people who really start to hate their bodies? That’s really hard to sit with.

BOYCE: And how do you expect a medical industry, medical community, or medical culture that can’t exhibit caution, humility, and patience to teach those attributes to the kid who might benefit from being cautious, humble, and patient with their own suffering, with their own development, and with their own lives?

LITTMAN: That was a really big question. And I don’t know if we can paint the whole medical establishment that way, but I think, again, we need a little bit more nuance. But, I think we can recognize that a lot of what’s driving this is the desire to relieve suffering. So, maybe we shouldn’t have so much animosity toward each other in each position, because, as parents, if your child is suffering, you want to do what’s going to help them. Then, the second bit is: Is this going to help them in the long-term? Is this going to help them in the short-term? 

Also, from physicians, psychologists, and clinicians, again, there is also this desire to relieve suffering. The difference of perspective is not whether you want to hurt someone or whether you don’t want to relieve their suffering. I think all of the players are really thinking and are driven by how do we relieve suffering and are coming at that point with different perspectives and different insights, based on what literature they’ve read, what literature they haven’t read, who they’ve talked to, how they’ve trained, who their patients are, and which patients come back.

I think that’s sort of the global problem. Again, this simplifying it into this is who they are, this is how you fix it, I think, is what has led us down this really fast path to move in one direction, because who wouldn’t want to fix it? And it’s only when parents and doctors are saying: Wait a second. This is not fixing it for some of these kids. Then, I think that’s where it changes.

BOYCE: It’s so difficult. It’s a moral question. If somebody comes up and says: “I can fix suffering.” Then, if you say, “I’m going to resist your fix.” Are you being unethical by resisting? Are you being unethical by being critical of that? You can be painted as “the bad guy,” if you’re saying: “Hold on. Let’s slow down.” Because you are de facto blocking people from ending their suffering and finding a cure.

LITTMAN: I think it depends on the framing. Who has perfect knowledge? Nobody has perfect knowledge, at this point, so, maybe we take a step back from demonizing. But, yeah, I see that you can be painted into a corner like: Why wouldn’t you want to relieve suffering now? But, if you think that’s going to make things worse in the long run, then that’s the way the conversation needs to go. We’re talking about short-term, we’re talking about long-term, and we’re talking about who this works for and who this might not work for. How do we figure that out? But it’s become so contentious.

AYAD: For me, I’m also curious, then, about: What is our relationship with suffering? How do we conceptualize disease? What is the role of a physician? What is psychological suffering? And what is the role of the therapist? And so, that is a set of questions that we all answer differently.

My perspective, as a therapist, personally, is not that my job is to help a person examine their life and find all the points of suffering and just systematically eradicate them by whatever means necessary. My job, especially in adolescence, which is a time full of suffering through the history of humanity, is to try and help the person look at the type of suffering they’re experiencing and asking: What is this about? What is this suffering? Why is this suffering happening? Is this something that I’m going to learn from? Is this something that is asking me to do something with my life or with my priorities or how I spend my time or how I relate to myself?

That’s kind of an interesting question, too. Because I think you’re right, Lisa, in that all of these different perspectives are about alleviating suffering and may also be about: What is the nature of human suffering? And what are we supposed to do with that suffering?

BOYCE: And how do you put that question into the form that a pill or a scalpel can answer it? If you can answer that, then you can say when not to use the pill or when not to use the scalpel.

LITTMAN: Yeah. There are some issues that are easily solved and resolved and some that aren’t, and there are some that you kind of don’t know. Again, it’s not coming out of nowhere, this desire for a quick fix. Because some problems are pretty straightforward, but the key is knowing when it’s not. 

BOYCE: Sasha, you brought up our conceptual relationship with suffering, and I was thinking at the same time: What’s our conceptual relationship with ignorance? How do we remind ourselves that there’s so much that we don’t know? And how do we establish a culture where it’s always progressing, but it holds space open as a sacred cornerstone of how progress happens as not through answers but through questions, facilitating that curiosity?

AYAD: Yeah. I think that kind of speaks to what you mentioned earlier, Lisa, which is that it may be premature to say that we have these evidence-based treatments for gender dysphoria. When, really, we don’t have great evidence, at least not applicable to this current population, maybe not so much in the long run. I think, at least, that would be an area that would be valuable for humility. 

And, on the other hand, if I were to put myself in the shoes of a parent, let’s say, or somebody who is treating a dysphoric child, who has really come to believe that this is a life-or-death situation; that this child might be very suicidal if they don’t get some kind of treatment, I can also understand why people say: You know what, you’re right; we don’t have all the long-term data for this, but this is the best thing we have right now. And I can really empathize with that perspective, too. Because, if you have a child who’s suffering and you have this hope that this treatment might make a big difference, at least can stave off the suicidality for now, of course I understand why that’s powerful. And what we’re also seeing is that, for some people, this treatment increases their suicidality. So, it’s really hard to know exactly what way to go.

BOYCE: Lisa, do you have any tips for people who find that the questions they’re asking are getting them into trouble? What has this topic or this adventure or this line of questioning taught you about adversity and courage and checking yourself and continuing down the path?

LITTMAN: It’s always important to keep in your mind that there could be different outcomes in terms of the research. I’m exploring, but, if the research shows that I’m wrong about x or y, I feel like I can understand that, or if it shows that I’m right I can understand that, but not to be so insistent on one narrative. That’s one thing.

In terms of responding to pushback from asking the questions, it’s important to keep a little bit of distance between what people are saying who don’t know you or don’t know your work or things like that. So, I have my inner circle of people whom I love and who love me back and people who know me and maybe people who don’t like me so much. Who knows? But I’ve got my inner circle of people who know me that I interact with. And then there’s like another layer of people who might know me. But then there’s this whole array of people who don’t know me at all who are able to conclude that I’m awful, I’m terrible, I’m the worst person ever. Or, I’m the best person, the hero, and whatever. And so, kind of keeping a distance from the decisions made without input and taking that with a grain of salt. That’s kind of how I dealt with that.

Sometimes you have to keep a little bit of a sense of humor, that a lot of the people who write and talk about my paper I’m pretty sure have never read it. So, it’s kind of hard to take that seriously. There was one comment that, when things were stressful, that really kind of made me laugh. Somebody said something like: “Oh, it’s parent reports! Something like that should be in the title.” Well, in the original title, it was there; it was just after a colon. So, apparently, somebody basically didn’t even read to the end of the title, to decide they knew everything and to make a comment about it. Again, taking everything with a grain of salt and constantly checking the integrity and making sure I can go forward.

BOYCE: How do you tell the story of yourself to yourself? How do you go through what you’re going through?

LITTMAN: I feel that I was sort of lucky to be in the right place at the right time. I have my experience as a doctor and a researcher and then I noticed something and then set out to explore it. When I saw that something, I was somebody who had research skills, so I feel like I was fortunate in that way and then fortunate again that I could speak about this topic. Because I don’t have the same kind of obstacles that someone with a kid going through this would have or somebody who is in a job position and seeking tenure. Again, I felt fortunate that I could say things and explore this area when other people can’t.

That’s how I see it, that I feel fortunate to have been in the right place at the right time, just looking for the truth, looking for what’s going on and how to explain it and how to help people. The folks that are detransitioners absolutely deserve to be helped. There is no question that they had an experience that was not well-documented. So, this is about really learning more and sharing what I learn.

I see this as I’m always learning. And I think we’re all always learning and just being open to keeping your eyes open to what might happen.

BOYCE: Do you have any final thoughts, Sasha?

AYAD: I just love what Lisa said. I think that’s so wise to take things with a grain of salt. I’ve also kind of had my fair share of either hyper praise or hyper demonization. And it’s really true; you cannot get too attached to either of those, because that will cloud your ability to stay open to what’s coming your way, what you’re learning through your work. You really have to find this grounded place in the middle where you let your work or whatever you’re experiencing bring up questions for you and help you figure out what to ask next. So, I just really love that.

BOYCE: Thank you both for joining me in this conversation. Truly, it’s been an honor to speak with both of you. And thanks for coming on, Lisa. It’s been great to hear your story, to hear you tell your story.