I owe an apology to anyone who knew me between the years of 2016 and 2018, when I somehow found a way to derail every conversation into rambling about how bad it was about to get for queer and trans people across the globe. The fact that – ultimately – I was proven right doesn’t detract from how annoying that had to be! I was fixated on the new websites where people ruminated upon the increasing numbers of youth coming out as transgender, arguing that this couldn’t be normal, that there had to be a nefarious cause, and that young people were being ‘brainwashed’ into thinking they’re trans by medical professionals, social media and peer pressure. Such websites, including Transgender Trend, 4thWaveNow, and Youth Trans Critical Professionals, were known to conservative news outlets, who cited their posts as evidence that young people seeking transition care represented an epidemic caused by the influence of a cult and egged on by a liberal medical establishment. These youth couldn’t really all be trans. Rather, these online circles insisted the new wave of trans kids had a form of gender dysphoria induced by society itself.
The term they gave to this purely speculative diagnosis was ‘rapid-onset gender dysphoria’ (ROGD), so named because parents participating in studies reported the sudden shifts. That conservative groups were promoting the term raised alarm bells for me because infamously homophobic lobbyists were openly planning to target trans rights as an electoral strategy. One such group, Family Research Council, openly stated their intent to use transgender rights as a wedge issue to weaken feminist, progressive and queer coalitions. The idea, they said in 2017, was that: ‘Trans and gender identity are a tough sell, so focus on gender identity to divide and conquer … If we separate the T from the alphabet soup we’ll have more success.’
As an early stage graduate student in psychology, who’d been out as nonbinary and queer for quite some time, I’ll admit that it was probably not the healthiest choice to actively seek out such spaces online and attend to their output. And yet, all these years later, ROGD as a concept has gone viral in conservative circles as the explanation for why trans youth seek support and care, and why those should be prohibited. During the 2022 midterm elections in the United States, escalating attacks on trans youth and those who support them relied on these talking points as common centrepieces of campaigns all across the US.
To be clear, there is a discussion worth having about the number of trans youth who are seeking recognition and care, and why that number is higher now than it has been in the past. I understand why, across English-language news media, stories about them have increased in frequency, and why so many of them report on increasing numbers of adolescents and young adults who self-describe as transgender or who seek transition procedures – ranging from simply changing clothes or using a different name (‘social transition’) to medical procedures such as hormone treatments to surgical interventions, like chest reconstruction or genital surgery. After all, both clinical experts and demographers across the globe have described these referral trends, with one Dutch team in 2020 calling them ‘exponential’. It’s normal and OK for someone to wonder: ‘Why are these numbers so much higher than previous estimates suggested?’ It’s even OK to wonder: ‘What happens if someone changes their mind? How do “detransitioners” fit into this?’
What’s less OK is how news stories fail to contextualise the issues. For example, The Telegraph website in 2018 described a ‘4,000 per cent increase’ in referrals in the UK for young people who were assigned female at birth – not specifying that any per cent increase from essentially zero (or 40 children in the entire population of the UK, which is 67 million) is going to look massive (the actual number of children referred in 2018 was 1,766 more than in 2009) and that such an increase followed the removal of barriers to accessing care. One headline in 2019 read: ‘4-Year-Old Can Begin Transgender Transition, Says UK Court’, neglecting to specify that the case was over whether the child could wear a girl’s uniform – not over anything medical or surgical. Vivid individual accounts of detransitioners often imply that regret is a common risk of transitioning when young, even though the evidence doesn’t support the suggestion, and some detransitioners now feel that their stories were inappropriately exploited.
While ROGD is unscientific, it provides an allegedly ‘scientific’ rationale for reactionaries
What’s definitely not OK is when such stories source claims from groups that have built their entire platforms around the concept of ROGD, as if such organisations were equivalent in quality and integrity to the medical consensus. Affiliates of organisations such as the Society for Evidence-Based Gender Medicine (SEGM) and Genspect argue in favour of banning transition for young people under age 25, partly because they endorse the neuromyth that adolescence lasts until 25, and partly because (according to them) the youth presenting for care can’t actually all be trans. A leaked audio recording from 2021 suggests that their leadership seeks to promote ‘desistance’ – meaning that the goal is to stop them from being trans in adulthood. Further, Stella O’Malley – Genspect’s founder, and a member of SEGM – admitted in 2021 in a Twitter Space meeting she co-organised with other anti-trans actors that her explicit goal is to make sure that those she regards as children (including legal adults) desist from seeking medical transition; any who do end up transitioning are viewed a priori as negative outcomes. In her own words (which you can listen to in audio from the meeting available here):
I suppose, uh, where I’m coming from this more than anything is, uh, to, um, make sure that children are, if – if at all possible – are stopped from medical transition. I think that’s the most important thing for me.
Lisa Marchiano, a psychotherapist and Jungian analyst who acts as an advisor and core member to both Genspect and SEGM, argues (on the basis of anecdotal or uncited evidence) that ROGD represents a ‘psychic epidemic’ and that therefore ‘many’ youth who come out as trans are ‘false positives’. Members of both organisations oppose attempts to ban conversion therapy internationally because they believe in the promise of psychotherapies aimed at ‘treating’ gender dysphoria so that the children can become cisgender adults. While such members sometimes claim to oppose conversion therapy, the model of ‘gender exploratory therapy’ that they advocate nevertheless explicitly advocates against youth transition procedures and (functionally) argues that every attempt should be made to prevent youth from undertaking transition through psychological interventions. In their eyes, these youth aren’t ‘really’ trans, they just have ROGD – therefore, treating them is harmful unless attempts to force them into a cisgender identity fail until their late 20s. Genspect specifically hosted a conference on ROGD in 2021 as well as a ‘ROGD Awareness Day’ event.
To such groups, ROGD is the answer to the collective denial that there could be this many trans youth naturally, and that there must be some striking causal explanation that ‘turned’ young people trans. While ROGD is unscientific, it provides an allegedly ‘scientific’ rationale for reactionaries who escalate attacks on trans people, and it has served as pretext for proposing and implementing rollbacks of trans rights. Here, I aim to explain why such denial doesn’t hold water among most experts and informed laypersons.
Bluntly, there is no solid evidence that ROGD exists. The study that birthed the term – circulated on, and designed for, these anti-trans websites – was first published in 2016 as a poster by the physician Lisa Littman, then at the Department of Behavioral and Social Sciences at the Brown University School of Public Health in Rhode Island. A self-described gender dysphoria expert, Littman later published her findings in a (now heavily revised) paper in PLOS One in 2018. At no point was a single trans person studied for these findings. Instead, Littman recruited an anonymous sample of people who claimed to be parents of trans ‘youth’ (ranging in age from 11 to 27) from websites including 4thWaveNow, Transgender Trend, and Youth Trans Critical Professionals. All three sources are infamous for transphobia, with 4thWaveNow in particular spreading unsubstantiated conspiracy theories.
Hate groups such as the Alliance Defending Freedom (ADF) and the American College of Pediatricians (ACPeds) have gotten in on the act as well. For example, ADF defended a professor’s ‘right’ at Shawnee State University to misgender trans students by using pronouns not reflecting their gender identity. In 2016, the presidents of ACPeds and of ADF signed an open letter condemning what was termed ‘gender ideology’. Such documents have successfully been used as ammunition in court to fight transgender rights.
To be fair, samples composed of parents are not inherently disqualifying. The TransYouth Project – a 20-year longitudinal study from Princeton University, which has been responsible for important findings on trans children – studies only children with supportive parents, as do other analyses from the same researchers. However, Littman’s ROGD research could not verify whether her own study’s participants were actually parents of trans youth, or simply trolls fabricating input. Further, Littman’s study violates basic research principles because her participants were not blind to the research hypothesis. Not only did the recruitment materials state that Littman was investigating the phenomenon that these websites themselves had conceptualised, recruitment was active while the concepts it sought to validate – social contagion and ROGD – were being reported on in the media as if already proven real.
Even ignoring these problems, Littman’s study is fatally flawed because it relies exclusively on parental hearsay – if indeed the respondents are actually parents. Her study cannot assess how accurately these parents assessed the timeline of their children’s gender incongruence. It shows only what unsupportive parents recruited from anti-trans web sources think happened. Parents aren’t always reliable sources about their children – particularly because queer and trans folk often come out to their parents last, long after they’ve come out to supportive friends. Littman’s study also suggested that ROGD could represent underlying mental health concerns – all while ignoring existing research suggesting that members of minority populations (including transgender youth) often have significant mental health concerns due to the stresses that being trans in an unsupportive society causes them.
These toxic ideas have gained purchase in political parties in France, Mexico, Sweden, Poland, Australia
These issues immediately incited a flurry of intense criticism of Littman’s paper, ultimately resulting in an extensive correction. At the time, I was still a graduate student, but read these criticisms with great interest – both because the controversy over Littman’s paper was personally relevant, and because, on the surface, her work resembled similar now-discredited arguments that stigmatised identities could be prevented or changed and were spread through social contagion. I remember reading claims on the Psychology Today website as late as 2010 insinuating that lesbianism or bisexuality among girls was increasing because of trends in pornography consumption, even though basic logic would dictate that it’s because homosexuality had been illegal in 13 states less than a decade prior, so you’d expect ongoing normalisation to lead more people to come out, and come out earlier (as polls demonstrate). One study even found that trans youth realised they were trans years before they came out to their parents, who only perceived that their children might be trans a few months before the child came out.
ROGD has proven to be a popular talking point in conservative circles, forming the basis for Abigail Shrier’s influential (and misleading) book Irreversible Damage: The Transgender Craze Seducing Our Daughters (2020), and referenced in US congressional testimony and by lawmakers. But, as far as the mainstream scientific community were concerned, this was the end of it: in August 2021, the Coalition for the Advancement and Application of Psychological Science (CAAPS) – now co-signed by 60 organisations – put out a statement to eliminate use of the term ROGD ‘given the lack of rigorous empirical support for its existence’.
Yet still, in June 2022, the Florida Agency for Health Care Administration put out a critically flawed report – which was used as evidence to not only ban state coverage for any transition procedures, but also to initiate and vote for rules to ban all youth medical transition in Florida – that referenced ROGD theory (as well as a number of unqualified and biased sources). Among those who went online to rebut the CAAPS statement on ROGD theory was the psychologist James Cantor – a frequent expert witness who nevertheless admitted under oath in 2022 that he has no experience with transgender youth.
The underlying assumption that the increase in youth can’t actually reflect real numbers has been used to curtail trans rights across the rest of the US (Alabama and Texas are extreme examples) and the world. The UK has become infamous for transphobia in recent years, earning the country a place alongside Poland, Hungary, Turkey and Russia, all condemned in a statement from the Parliamentary Assembly of the Council of Europe. These toxic ideas have gained purchase in political parties in France, Mexico, Sweden, Poland, Australia and others. Part of the anti-trans movement represents coordination between far-Right political groups and self-described ‘experts’ who promote ROGD. At times, religious organisations (such as the Catholic Medical Association) are involved.
Transphobic movements continue to promote distrust of scientific expertise, even when consensus is deep. ROGD has been opposed by some of the most prestigious bodies in science, medicine and human rights: the European Court of Human Rights, the American Academy of Pediatrics, the World Professional Association for Transgender Health (WPATH), the US Professional Association for Transgender Health, the Australian Professional Association for Trans Health (AusPATH), the American Psychological Association, the American Psychiatric Association, the Endocrine Society, to name but a few.
In his rebuttal of the CAAPS statement, Cantor suggests that this stance constitutes neglect of science. He argues it doesn’t matter whether ROGD exists (and he concedes that it may not). What matters, in his view, is that there has been a large increase in referrals for gender dysphoria in recent years, and that those patients don’t match the ‘well-characterised’ profiles of trans people at clinics in previous years. Cantor specifically draws attention to age of onset – early childhood now, adolescence in the past – and sex ratio, with more patients than ever assigned female at birth.
But these points hold only if trans people really were well-characterised years ago, and if there are no compelling, obvious reasons for trans referrals to increase worldwide today. Neither of these situations are true.
Most glaring, calling past profiles of trans people ‘well-characterised’ is unsupportable. To begin with, the most recent version of the Diagnostic and Statistical Manual for Mental Disorders (DSM-5-TR, released in 2022) puts the number somewhere between 0.5 per cent and 2.6 per cent depending on how you ask the question, based on population studies. The previous version of the DSM (the DSM-5, released in 2013) estimated the prevalence of gender dysphoria to be between 0.005 per cent to 0.014 per cent for those assigned male at birth, and 0.002 per cent to 0.003 per cent for those assigned female at birth – ostensibly by extrapolating from the rate at which people sought care for gender dysphoria at clinics, although the DSM-5 cited no references for these statistics whatsoever. Even in 2013, those numbers were an absurd underestimate. A meta-analysis argued in 2015 that relying on estimates from individuals attending clinics could never be accurate when most trans people remain closeted and avoid seeking care.
What’s more, how trans people were studied and conceptualised prior to 2013 was questionable at best and bigoted at worst. In Cantor’s own review in 2019 of ‘outcomes of research on [gender dysphoric] children’, most of the 11 studies reviewed weren’t even on gender dysphoria per se. Three of Cantor’s references (all dating from the 1970s and ’80s) studied ‘feminine behaviour’ and the ‘deviant outcomes’ it was associated with in boys – which (at the time) included homosexuality as well as transsexuality and transvestitism. For the first of these studies, homosexuality was still exclusively considered a mental illness. Indeed, almost all the studies focused exclusively on those assigned male at birth. Of these studies, five contained fewer than 20 subjects each. Only two had more than 100. Further, the ‘treatments’ offered in a majority of Cantor’s referenced work were mainly aimed at preventing these children from pursuing transition, and the general practice of the day was attempting to reduce gender nonconformity.
The psychiatrist Robert Stoller in 1970 described the goal of treatment as, ‘ideally … shift[ing] the boy to the same degree of masculinity we like to see in any boy … But we would consider any masculine development as an improvement.’ He went on to say that his idea of a ‘successful’ case was a ‘moderately feminine’ heterosexual man, with a middling case being a ‘homosexual man’ – which he described as a ‘far happier outcome’ than being trans in adulthood.
Even therapists who were relatively accepting of homosexuality (and who actively campaigned to remove homosexuality from the DSM-II) took a narrow view of transsexuality. While the sexologist Richard Green objected to the idea that parents try to ‘maximise’ the chance that their child would grow up to be heterosexual, he did so primarily because he believed such efforts wouldn’t work; untreated children, he said in his book The ‘Sissy Boy Syndrome’ and the Development of Homosexuality (1987), had little risk of growing up to be trans, anyway. An incredibly influential figure and the former editor-in-chief of the journal Archives of Sexual Behavior, Green never altered this narrow view of transness compared with queerness; as late as 2017, he remained ‘convinced that it is a helluva lot easier negotiating life as a gay man or lesbian woman than as a transwoman or transman’ and that therefore attempts to prevent transness were justified.
In fact, officially sanctioned transition procedures were generally inaccessible to minors prior to the development of Dutch and Canadian Gender clinics in the late 1990s. Even then, therapists charged with treating gender nonconforming youth at these clinics took a narrow, restrictive view of transition, and saw the attempt to foster a cisgender identity as a critical step. In her book Trans Kids (2018), Tey Meadow details how early gender clinics routinely tried to prevent transition if possible, and how gender nonconformity was aggressively policed.
Because gender conformity was more strictly enforced for boys, trans boys may have flown under the radar
It took a long time for things to change, even a little bit. Until 2013, being trans was considered a mental illness. Transition was to be used only if other efforts to ‘cure’ this illness had failed by adolescence. In contrast, modern criteria – such as the WHO’s International Classification of Diseases (11th Revision, effective from 2022) and its discussion of gender incongruence, and the DSM-5’s discussion of gender dysphoria – viewed being trans not as a mental illness, but as a normal (if uncommon) segment of the population.
The fact that modern profiles of trans youth differ drastically from past profiles reflects differences in referral patterns: not only are many trans youth now brought into a clinic for transition-care by supportive parents, many of the children in prior samples came in alone; they were generally viewed as gender nonconforming (not following other people’s ideas or stereotypes about how they should look or act based on the female or male sex they were assigned at birth) and may or may not have been trans.
Further, even care for adults often was denied if the adults in question did not wholly conform to stereotypes of their newly affirmed gender. An AusPATH report in 2022 on the history of trans healthcare in Australia details how trans people were denied care; sometimes denial could be as petty as clinicians not finding a client attractive.
And because gender conformity was (and is) more strictly enforced for boys, trans boys may have simply flown under the radar and never been counted at all, leading to the shift in the sex ratio we see today. These earlier referral patterns are also likely a reason why papers from this period claimed that, by adolescence, children often outgrew identifying as trans – a phenomenon called ‘desistance’, considered exceedingly rare today. In what could be seen as a contradiction, some of these same authors found that the intensity of gender dysphoria – the main focus of the modern diagnostic criteria – was the strongest predictor of ‘persistence’.
In short, there is a straightforward explanation why current samples of trans youth don’t resemble past samples: samples from the past were not well-characterised. They were small and inadequate, collected when parents were unsupportive, and the goal was to prevent adult transition if at all possible. Indeed, the same 2020 Dutch paper that described the rise in youth seeking care as ‘exponential’ concluded that this increase was mainly due to adolescents with gender dysphoria being more willing to seek help than they were in the past, with greater family support.
Today’s increased willingness to seek help, along with increased family support, are themselves entirely expected because of the social, legal and cultural shifts surrounding queerness and transness across the world. Consider the US. Prior to 2010, you generally needed an extensive medical transition, including genital surgery, to change your ID documents – meaning you couldn’t travel, vote, apply for a job, or even buy alcoholic drinks without ‘outing’ yourself for harassment and abuse – most of which was legal, because there were no legal protections specific to trans people, and hate crime laws did not protect either queer or trans people until 2009. Your employer could fire you for transitioning as late as 2020, when Bostock v Clayton County was ruled upon.
Worse, most insurers would not cover medical transition until a specific Barack Obama-era ruling on Section 1557 of the Affordable Care Act effectively forced them to in 2016. This ruling, incidentally, has been a frequent target of legislation and litigation ever since. Writing in The Washington Post in 2019, Katelyn Burns described the then-president Donald Trump’s attempt to overturn the ruling and ‘erase’ these trans protections as the ‘cruelest thing the Trump administration has done to trans people yet’. These attempts, incidentally, were made with the full support of the then-nascent SEGM (for more details, see here). At present, the status of this Section forms a key foundation for the rights of trans youth to healthcare in the US – without it, care was prohibitively difficult to access. This ruling was preceded by the Obama administration changing policies for the issuance of passports in the 2010s; nowadays, many states make obtaining legal recognition of your experienced gender easier (though several do not).
The UK, meanwhile, enacted the 2004 Gender Recognition Act – allowing trans people to apply for documentation changes – in part because a European Court of Human Rights ruling forced it to. In 2017, that same court ruled that it was a violation of human rights for EU countries to require trans people to be sterilised to obtain identification affirming their experienced gender. At the time, 22 EU countries mandated sterilisation – an unnecessary step that not all trans people desire, as evidenced by the number of trans dads. AusPATH’s 2022 report on the history of trans healthcare in Australia points out another factor: fewer people sought care in the past because that care was not available. Relatively few physicians had the competence and willingness to provide the care sought, and this was doubly so for minors.
Claims that there can’t be this many trans youth rest upon misunderstandings of gender diversity
Even if they got past all that, trans people still had to contend with isolation from other trans people on the one hand, and with misunderstanding and ignorance – not just from the public, but from medical and psychiatric professionals – on the other. While trans-friendly publications, organisations and spaces have always existed – such as the Erickson Educational Foundation (founded in 1964 by a trans man, Reed Erickson), the Janus Information Facility, community magazines such as Transgender Tapestry and FTM International, clubs like the Tiffany Club of New England, and the communities that the German sexologist Magnus Hirschfeld served before the Nazis burned them to the ground – most trans people lived in isolation from one another, with little to no means to communicate with each other before the internet age. According to Genny Beemyn’s ebook Transgender History in the United States (2014):
the most significant factor in the development of a national transgender movement may have been the rise of the Internet in the mid-1990s … especially for the participants under 50 years old, for whom the Web was their primary method of meeting others like themselves and accessing resources. The older participants less commonly socialised virtually, but many first recognised themselves as transgender and realised that they were not alone through exploring the Web.
Now, people are at least aware that trans people exist and can be happy with their lives. When personalities such as Thomas Beatie (in 2008, a curiosity as ‘the pregnant man’), Caitlyn Jenner, the sisters Lana and Lilly Wachowski – directors of The Matrix (1999) – and the actors Chaz Bono, Laverne Cox and Elliot Page came out, they generated enough media attention that, by 2014, Cox was the subject of a Time magazine cover, headlined ‘The Transgender Tipping Point: America’s Next Civil Rights Frontier’.
In sum, claims that there can’t be this many trans youth rest upon misunderstandings of gender diversity and care models that alienated both patients and their parents – or that didn’t exist at all. The social, legal and clinical environments in which today’s trans youth find themselves are radically different from the first-line conversion therapy previously employed. Nowadays, care is available for them, and although they are often on waitlists years long, there is enough media representation for them to see themselves. The skyrocketing rate of trans youth should be entirely expected given these shifts. This is obvious – which is precisely why the expert consensus has arrived here.
In late 2022, six years after I’d first heard of ROGD, I am furious almost all of the time. Not because I am nonbinary, and not because of the barrage of news cycles. I am furious as a scientist that this idea just won’t die. Despite it being thoroughly discredited, rejected by the scientific community, and utterly lambasted on TV in Last Week Tonight with John Oliver, I’m still talking about ROGD, I’m still talking about social contagion, and I’m still talking about pseudoscientific conspiracy theories, when the best evidence that we have supports what practitioners call the gender-affirming care model.
The basic ideas are that practitioners respect the gender identities that young people express and that we all accept the stages of transition that are appropriate to both the age and the developmental stage of youth. Before puberty, this means allowing social transition – which can range from something as simple as a new haircut or different types of clothes, to trying out a new name and pronouns. For adolescents and young adults, this usually means allowing puberty blockers (which are not irreversible) and hormone therapies. The keyword here is ‘allowing’ – youth should at no point be coerced or forced into stages of transition that they do not wish to undertake. Gender-affirmative care generally entails a therapeutic team that work with both the young person and their family to decide upon the best course of care for them.
The best evidence we have suggests that gender-affirming care is helpful for the mental health and general wellbeing of trans youth. There is no evidence that gender-affirmative care is harmful. And please note that I am talking about best quality evidence because, while that evidence might be rated as ‘low quality’ compared with the gold standard, so is the evidence for some routine drugs like statins. Evidence for ROGD is far worse; as Cantor more or less cops to, it’s a solution to the ‘problem’ of too many kids being trans. And as the writer Mallory Moore asked on Medium in 2022: ‘How many trans kids should there be?’
If I’m being honest, after a year of legwork for this essay, that’s what gets me most. ROGD might be a solution to a non-problem, but there are real problems in trans healthcare and trans science that we can’t have productive conversations about because we have to waste our time with this. Just being an expert doesn’t make someone automatically right – and even respected names can screw up. There is room to criticise practising experts and demand reforms. This is why trans people all across the UK actually supported the closure of the NHS Gender Identity Development Service in favour of a regional model, and why trans people across the globe criticised both the draft and the final versions of the WPATH Standards of Care (8th version). Personally, I was annoyed by the lack of guidance for providing aftercare to detransitioners or supporting them, believe it or not! Criticising experts is necessary – they’re only human, and even the best of them make mistakes. But these criticisms should be based on actual problems – not astroturfed hearsay – and the proposed solutions should be refinements to the existing model, not regressing back to the late 1980s, when myths and misinformation ruled the day.