ROGD is an Attack on Affirmative Treatment

ROGD stands for rapid onset gender dysphoria which refers to the idea that being transgender can rapidly emerge during teenage years without warning, at least without warning to parents. The claim is that this behavior is triggered by “contagion” from peer groups and information from the Internet. I will get to critiquing the current controversial report by Lisa Littman on ROGD but first I will play Rachel Maddow and give you some background for perspective.

When the academic gender centers went out of business in the late 1970s, they lost control of the leadership of transgender treatment. As it turned out, they could not have done transgender people a better favor. Subsequently, a free market developed of mental health and medical providers, not just in the United States but worldwide. Transgender people voted with their feet and dollars to seek “affirmative” treatments. Transgender people who did not want to go through transition (about 90% of transgender people) found affirmative counseling to be useful when they needed help. It assisted them with the social problems and rejection of being transgender and took away some of the guilt created by a gaslighting, kyriarchical (subjugating) culture. To those who wanted it, these affirmative counselors also provided encouragement and safety guidance for transgender people to enlarge their transgender experiences to explore their congruent gender and the possibilities of authenticity. Counselors provided patient management services to those who wanted to explore transition. The services included finding affirmative endocrinologists and surgeons. These activities were supported financially by transgender people and sometimes their insurance, not by academic scientific grants or by the state. The affirmative environment continues to the present day. It has contributed to the current increased visibility and assertion of civil and political rights for transgender people. Compare this with the Canadian CAMH experience which resulted in the use of reparative therapy when financial support and control came from the government. Parents were threatened by the state that they would lose their children if they did not enforce reparative therapy procedures such as toy censorship and behavior modification.

To the shame of United States science, which prides itself on being the worldwide scientific leader, a clinic in the Netherlands came up with an effective affirmative protocol for transkids. It is believed to be relatively safe but it has only been tried in the last decade. The protocol involves drugs to block puberty and give the children time to experience life in their congruent gender. The goal is to give them time to gain experience to allow them to decide whether they should transition. If they do not want transition, puberty will occur based on sex assigned at birth. The U.S. community has been quick to adopt and improve on this protocol. I should note that the protocol is carefully executed by a team of parents and various providers–medical, mental health, and endocrinology. And the transkid has to be persistent, insistent and consistent about being transgender. This protocol has only been in use for a few years but parents and children have judged it to be preferred to the stress of secrecy or overtly “toughing it out” which facilitate depression, anxiety and, in some cases, suicide.

Although affirmative approaches won out, competing treatments and causal ideas for transgender people never completely disappeared even though they had been found to be ineffective and sometimes dangerous. Jan Morris reported how Harry Benjamin saw the situation as of the 1960s for the subset of transgender people he treated:

He had explored every aspect of the condition and he frankly did not know its cause; what he did know was that no true transsexual had yet been persuaded, bullied, drugged, analyzed or electrically shocked into and acceptance of his physique. It was an immutable state.

Jan Morris, Conundrum, p. 114.

Modern reparative therapy for transkids involves variants of the treatments that Benjamin listed. The two most common today for children are jawboning and operant conditioning. Jawboning is akin to bullying and operant conditioning involves punishment by withdrawal of rewards.

Psychodynamic explanations of being transgender have also not completely disappeared. Many mental health providers have been trained and continue to be trained in psychodynamics. It refers to mental processes and intervening variables that are not observable but are used to explain and sometimes treat people with mental problems. Psychodynamics started with Sigmund Freud who took concepts from early psychological studies of the unconscious and sexualized them. The belief was that psychoanalysis and other procedures could be used to explore psychodynamics and “cure” mental problems. Of course, mental processes cannot be observed so it is impossible for psychodynamic ideas to be empirically tested and therefore psychodynamics does not constitute scientific theory. Even in his day, Benjamin indicated that analysis was ineffective in the above quote. I have found over 20 psychodynamic explanations that have been offered for being transgender and none of them rises to the level of a scientific theory. They typically predict all possible outcomes and so are too vague to be subjected to empirical test.

Which brings us to the present day and the story of ROGD. It begins with several websites started ostensibly by parents of teenage transkids who claimed that their children, without warning, abruptly came out as transgender. They were also were unhappy with the treatment they got from mental health and medical providers.

Discarded and dangerous alternative treatments and associated causal ideas have been featured on these websites. Reparative therapy is championed based on cultural cisgenderism. The rationale is that cisgenderism is the natural state of affairs and transgender children must be disciplined to behave in a gender category assigned by natal sex or they will greatly suffer in later life. I know what that is like. Aversion therapy is implied based on the based on the idea that sexual arousal motivates transgender behavior. If you saw A Clockwork Orange you saw aversion therapy. It involves making the person nauseous using drugs and pairing nausea with stimuli that accompany the behavior which is to be eliminated. For transgender people, sexual stimuli (e.g. same-sex clothing) were typically selected to reduce sexual arousal. But this approach only suppresses unwanted behavior in the experimental environment. The idea that being transgender is due to sexual arousal pathologizes and causes people to view transgender people as being sexually “perverted.” This is a common basis for misinformed public rejection.

We can now add psychodynamics as a non-scientific causal idea and psychoanalysis to the list of discarded therapies and causal ideas which appear on these websites because of the Littman paper.

Dr. Lisa Littman

Given these websites of presumably upset and disgruntled parents, along came Lisa Littman at Brown University who saw an opportunity to find out about these parents who were unhappy with affirmative treatments and their children. She took opportunistic advantage of the parents and the websites to apply her notions of psychodynamics to being transgender. Littman proceeded to send out an Internet link through these websites. The link was to a survey site for parents to fill out a survey to provide information on respondent experiences. According to her report, she received about 250 responses. The dissemination of this link was not controlled so anyone could have responded to the survey, not just parents, and parents with positive experiences were not recruited for the survey. Littman refers to this as an available sample but scientifically this also termed an uncontrolled, biased sample.

The collected data showed that the children involved were clearly transgender as indicated by changes of presentation involving dress, hair and behavior, by their verbal statements, and by their requests to consult with providers about their suspected transgender status. The children were mostly above average or average intelligence (many were in gifted and talented programs). They consulted their peers and Internet websites to find information on being transgender. Even though Littman termed this information gathering as “contagion,” she stated that she did not believe that this contagion was the cause of their being transgender. She left that for her psychodynamics.

“Contagion” to most people connotes disease caused by germs or other agents and signifies pathology or a poison (Merriam-Webster, 2018). The third meaning of contagion is “rapid communication of an influence or doctrine.” It is possible that Littman intended the latter but that connotation implies that children can be indoctrinated into being transgender. There is no empirical evidence for that. Whatever meaning is assumed, the word “contagion” was clearly misleading for general audiences and wrong scientifically. If it was chosen to be sensational, it is totally inappropriate on ethical grounds.

Her a priori psychodynamic belief was that transkids had undergone early trauma and that this trauma was responsible for them being transgender. She designed her survey around this notion. She collected trauma information based on her belief but did not collect information on alternative hypotheses indicating that her real intent was to apply psychodynamics to transkids. Sexualized trauma causation is a staple of psychodynamics even though many times the patient cannot initially even remember a trauma. Scientifically it has been shown that the course of certain types of analysis, false memories of trauma can be “recovered.” Her psychodynamic interpretation was that being transgender resulted from an ineffective coping mechanism to deal with the trauma. As Littman defined it:

A maladaptive coping mechanism is a response to a stressor that might relieve the symptoms temporarily but does not address the cause of the problem and may cause additional negative outcomes… [Transgender] Transition as a drive to escape one’s gender/sex, emotions, or difficult realities might also be considered when the drive to transition arises after a sex or gender-related trauma or within the context of significant psychiatric symptoms and decline in ability to function. Although trauma and psychiatric disorders are not specific for the development of gender dysphoria, these experiences may leave a person in psychological pain and in search of a coping mechanism.

Of course, these statements are unprovable because they involve internal mental processes and intervening variables that are not observable. Respondents reported that some of the children had received trauma, but there were no comparisons made to the frequencies of occurrence for non-transgender children or the population. Only 10% of the reported trauma involved sex/gender and this category was not well defined. It should also be pointed out that one child’s trauma is another child’s growth experience. It is not just the event, it is the injurious effect on a person that makes it traumatic.

Littman asked the respondents to judge their children on psychiatric criteria which mental health providers use for diagnosis of childhood and adult transgender gender dysphoria. Gender dysphoria is a recent billing code for treatment of people who meet certain criteria in the Diagnostic and Statistical Manual of the American Psychiatric Association (2017). This code is mainly used for transgender transition treatments. Only about 10% of transgender people meet the requirements for gender dysphoria. Littman included most of the criteria except for one—whether the transgender children were debilitated or in distress because they were transgender. This latter criterion is a sine qua non super criterion and usually makes the difference between those who are just transgender and those who want to seek medical treatment to change their bodies through transgender transition. Littman evidently simplified the criteria for respondents but did not post these simplified criteria in her paper. (It should be stated that there is nothing in Littman’s published background to qualify herself to actually understand and use these diagnostic criteria. She has degrees and training in medicine and public health.) Using this flawed methodology, Littman interpreted the data to mean that the children were not transgender in childhood but were transgender in adolescence and adulthood.

However, if the DSM criteria are followed strictly, none of the children met the requirements for gender dysphoria in adolescence and adulthood because the requirement of distress or debilitation was not considered. Although from incidental reporting, it is clear that some children desired to go into an affirmative program and perhaps transition, a diagnosis of gender dysphoria is not indicated both because of not meeting all the required criteria and because the parents were given simplified criteria. But the biggest reason is that the criteria are intended to be evaluated by trained providers, not parents. Littman cannot confirm that any of the transgender kids were gender dysphoric which is a major assumption of the concept of Rapid Onset Gender Dysphoria.

One of the interesting (to me) but overlooked findings is that most of the transkids had been previously diagnosed with anxiety and depression. Littman used this data to pathologize the transgender kids but these are also frequent effects of secrecy. Were the children living in secret about being transgender from earlier childhood? We do not know from the report. The transkids were not asked.

Another overlooked finding is that parents reported that most (64%) of the female children had been previously come out as bi, lesbian or pansexual. There were no reports that parents found coming out in these sexual orientation categories as abrupt or shocking. Do children come out first with their non-heteronormative sexual orientation before coming out with being transgender because it is more socially acceptable and may not require body changes as in transgender transition? When a child comes out as transgender, there is typically a “grieving” process for a lost child. Is this why parents reject coming out as transgender and not in non-heteronormative sexual orientations? This hypothesis squares with my personal experience with transkids in this age group because of serving as a volunteer science teacher at an affirming school and in listening to them in support groups. But it is a hypothesis that Littman should have considered if she had known about the psychology of secrecy. Again, the transkids were not asked.

The Littman paper is scientifically unsound and its assertions negatively impact transgender kids, particularly the assertions that could be taken to be sensational. The immediate impact is that parents may be hesitant to bring transkids to qualified providers if being transgender is suspected. (There have already been reports of parental hesitancy to admit their children to affirmative treatment programs because of this controversy). Children should not be restricted from finding out about being transgender from their peers and the Internet but can get the best information from trained providers. Since many parents frequently do not know much about being transgender, those sources are the only way that children can become informed patients when it comes to meeting with a provider. Because of their transgender behavior, transkids children are often subject to psychological and physical abuse and trauma by parents and family. But no empirical studies show that they become transgender because of trauma. By discrediting affirmative treatment, the Littman paper may expose transkids to even more abuse.

The long-term negative impact of the disgruntled parent websites and this report is that transkids and transadults may be branded as pathological. They already suffer greatly from cultural rejection and pathology provides some handy reasons for that cultural rejection. Although science is not perfect, it is the best tool we have to deal with the idea of ROGD and similar pathologizing ideas about being transgender.

Reference: Jan Morris, Conundrum, New York: Harcourt, 1974, page 114

Care to make a comment on this post? Login here and use the comment area below.

Tags: featured, Lisa Littman, Rapid onset gender dysphoria, ROGD, Transgender

Category: Transgender Body & Soul, Transgender Community News