Tuesday, November 13, 2018

The "Rapid Onset Gender Dysphoria" Controversy at AACAP's Annual Meeting

Last month, when I saw the program for the Annual Meeting of the American Academy of Child and Adolescent Psychiatry (AACAP), my professional society, there was one session that caught my eye. It featured a presentation by Lisa Littman, MD, MPH titled “Peer Group and Social Media Influences in Adolescent and Young-Adult Rapid-Onset Gender Dysphoria.” In case you’re not familiar with the term “rapid-onset gender dysphoria” (ROGD), it exploded into prominence and controversy in August following the publication of a paper by Dr. Littman reporting data from parents who claim their children started to identify as transgender after being exposed to some form of online influence, social trend amongst their friend group, and/or acute stressor.

This story has been covered extensively in publications like Science and Slate, but in short, the response to this paper was rapid and highly polarized, with the transgender community generally condemning it as flawed and transphobic, while others rushed to defend Dr. Littman from “ideologically-based attempts to squelch controversial research evidence.”

I’ve attended several previous AACAP meetings, where educational sessions tend to have a staid consistency: An academic child psychiatrist or psychologist presents a topic related to their research or clinical area of expertise, there is polite applause at the end, followed by a fairly mundane Q&A in which audience members either praise the speaker and/or talk about how the presentation relates to their own clinical experiences. You may not be surprised to learn that what happened following Dr. Littman’s presentation was very different.

For her presentation, Dr. Littman started by summarizing research from the past decade showing that the age of those presenting to gender clinics as transgender have become older (i.e. adolescents as opposed to pre-pubescent children), with a higher proportion being female-at-birth than male-at-birth, which is the opposite of the previous historical pattern. Dr. Littman noted that around 2015, parents of some transgender teens started reporting on online forums that their teens’ transgender identification seemed to arise in the context of belonging to a peer group in which multiple members came out as transgender around the same time, as well as adopting other behaviors like binge watching of transition videos online.

According to Dr. Littman, this raised the concern that there many be social contagion occurring, and she specifically cited the example of online websites with “pro-ana” or “thinspiration” themes that encourage anorexic behavior. Her study started in 2016 with a Surveymonkey survey that was shared with parents who frequented forums where they shared their experiences of their teens’ “rapid-onset gender dysphoria.” Although Dr. Littman noted that ROGD is a term used by some parents and clinicians but is not an official diagnosis, she did not show much skepticism about the concept, basically accepting it as valid and deserving of research.

Her study, based on the responses of 256 parents who claimed their teens had ROGD, found that in 2/3 of these cases, those teens were part of a social group in which at least one other friend came out as transgender, and in an astounding 36.8% of the cases, the majority of the friend group came to identify as transgender. Also, 80% of the cases reportedly had zero symptoms of DSM-5 Gender Dysphoria before identifying as transgender, 62% had a prior psychiatric diagnosis, 45% had non-suicidal self-injurious behavior, and 58% were described as being easily overwhelmed by strong emotions. Dr. Littman put forth the hypothesis that the youths described in her study are adopting a transgender identity as a maladaptive way of coping, and she provided some example cases that parents shared, such as teens who began to identify as transgender after experiencing sexual assault, school failure, or bullying based on their appearance. In conclusion, Dr. Littman stated that more research is needed on ROGD, and that in future studies, she hopes to involve the transgender youth themselves rather than just their parents.

Following Dr. Littman’s presentation, there was no applause before several audience members launched into questions. Some were more civil than others, but pretty much all were critical. One audience member pointedly asked Dr. Littman what she had previously studied in her research (OB-Gyn public health issues), and whether she has worked with any transgender patients in the past (she has not), before concluding by telling Dr. Littman that she was not qualified to do this kind of research. Another questioner at the end repeatedly asked her “why did you do this study” and “what’s wrong with taking on a different gender identity,” to which she would only say that we should keep open the possibility that there may be social contagion occurring, as with her anorexia example earlier. The questioner then pointed out that unlike anorexia, a transgender identity is not by itself harmful.

Before every presentation at AACAP, the speaker is supposed to disclose any financial conflicts of interest, and I don’t recall Dr. Littman reporting any such conflicts. However, the most relevant conflicts often don’t come from financial interests, but from one’s own biases or personal allegiance to a particular theory, the pressure to publish, the desire for fame and validation, etc. To me, the most frustrating aspect of Dr. Littman’s presentation was that she remained opaque regarding her own views and why she undertook this study. Is she some sort of right-wing anti-trans ideologue? Is she an anti-PC academic who lacks a filter and doesn’t mind controversy, like a mild Jordan Peterson? Could she just be a guileless public health researcher who unwittingly stumbled into a hornet’s nest? Or is Dr. Littman herself a parent (or a friend of a parent) who had frequented the ROGD forums looking for support and answers? I don’t know if Dr. Littman discussing her own experiences and opinions would have made her study any less controversial, but at least it would have felt more honest and transparent.

The discussant (a.k.a. summarizer and moderator) of the session was Dr. Scott Leibowitz, director of the gender program at Nationwide (Is On Your Side) Children’s Hospital in Columbus, OH. I did not envy the task before him, but Dr. Leibowitz admirably pointed out that child psychiatrists are often caught in the gray zone between opposing sides who view gender issues as black-and-white, whereas we've tended to recognize that a person’s gender identity is formed from biological, psychological, and social factors. He gently but persistently critiqued Dr. Littman’s study as far from neutral in how it presented the concept of ROGD to parents taking its survey. He pointed out that in a political climate where transgender people remain a marginalized minority under constant attack, any research that may affect their well-being has to be done with great sensitivity and consideration of the potential consequences, which this study was not. But he also pushed back against those audience members who thought Dr. Littman should not have gotten involved in an area in which she had no prior experience or expertise.

Dr. Leibowitz’s summation reminded me of the following quote, taken from the previously linked article on Jordan Peterson:

We are living through a time of pervasive rhetorical overkill and genuine fear. In times of extremism, moderation itself can come to seem the greater enemy to those ideologically possessed, in part because it is the true danger: The public will tend to move toward it by default, and thus the instinctive recourse by those who sense the fragility of their extreme doctrines resort to coercive means to prevail in arguments they would not otherwise win.

I hope that moderation can ultimately prevail, and I greatly appreciated Dr. Leibowitz’s approach. But I don’t think there was any applause either at the end of Dr. Leibowitz’s summation. Was the audience fearful of showing where they stood? Also, Dr. Leibowitz did not tweet about this session afterwards, even though he tweeted about many other LGBTQ-related sessions at AACAP. I hope this wasn’t because he was wary of the immoderates of the Internet. In today’s political climate, I really wish the “silent majority” of those in the middle would not be so silent.

Sunday, March 11, 2018

Reflections on a Bully From High School

Brett was the biggest jerk on my JV soccer team. He was short, stocky, and slow. Yet he also had a beautiful shot off either foot, and he was our star striker. He was the one Coach called upon to take all of our free kicks and PKs. He had more goals than anyone on the team.

I played defense, along with my friend Luke. Luke and I rarely got the chance to shoot the ball and almost never felt the glory of scoring a goal. While scrimmaging in practice, we got to spend plenty of time with Brett, since he would just loiter near the goal, never running back to help his side on defense. When the coach wasn’t looking, Brett would try to trip us or kick us in the shins, and sometimes he even jumped on my back and tried to wrestle me to the ground. During games, if the coach asked him to do something he didn’t like, he would curse and mutter insults not quite under his breath. This once led the captain of the opposing team to ask incredulously, “How can you talk to your own coach that way?”

During water breaks, Brett's favorite pastime seemed to be making fun of Luke and myself in front of the whole team. With me, Brett usually mocked my appearance, since I was very nerdy and not yet good at hiding it. There was a silly rumor going around the school that Luke had a testicle removed due to a medical condition, and Brett mercilessly and repeatedly mocked Luke by calling him “One-Ball” and telling him he would never have kids. Most of the team laughed along with Brett.

In the offseason, some of my teammates and I played on an indoor soccer team, which my dad helped coach. In the confined space of an indoor arena, Brett seemed to get even more personal with his insults. He owned the official Adidas soccer ball that my team used. He would tell me, “This ball cost $80. Since you get all your clothes at K-Mart, it’s worth more than your entire wardrobe!" Yet around my dad, he seemed more friendly to me, and I never heard him swear at my dad. On several occasions, he even said to me, “Your dad is so cool!” Back then, I interpreted those comments to be further mockery, which I did my best to ignore. Now, I’m not so sure.

My dad was a frequent spectator at my JV team’s games. He couldn’t make it to the afternoon games, but he invariably came to all of our evening and weekend games. Brett’s parents, on the other hand, were never there. From what I heard, his father was out of the picture, and his mother had to work 2 jobs to support him and his older brother, who was kicked out of high school for drug use. Brett’s brother did sometimes show up to our games, watching quietly from the sideline and usually leaving before the game was over.

There were some occasions when Brett seemed to show a softer side. During lulls in practice, I remember seeing him sometimes looking wistfully up at the sky. Out of the blue, he said to me once, “You see those birds over there? I wish I could be a bird and just be free and fly away.” At the time, I did not give a crap what he may have been trying to fly away from. But now I wonder.

I thought about Brett this week when Facebook suggested I add him as a friend under “People You May Know.” I did not. But he looked happy in his profile picture, and out of curiosity, I googled his name and found that he has moved far from our hometown, and he works as an operations manager for a fancy restaurant chain. I do not know if he has any kids, but if he does, I hope that he is able to go to all of their soccer games.

Saturday, January 20, 2018

Is Apple Responsible for the Well-Being of Our Kids?

I was surprised to see that the most-viewed article on the blog this week was one that I wrote almost 5 years ago, What to Do if Your Kids Are Obsessed with Technology. (Thanks to whoever shared that on Facebook!) Reading it again, it seems to hold up fairly well, and I would still offer the same advice to parents wondering what to do if their young one seems too drawn to screens.

However, many things have changed since 2013. Smartphones have gotten so ubiquitous that every teenager I see has one, and most children older than 8 or 9 seem to have one as well (and if not a smartphone, then almost certainly a tablet or Chromebook). Snapchat and Instagram have gotten ever more entrenched as the platforms of choice for young people’s socializing and selfie-expression, and games with addictive mechanisms have proliferated like weeds. We’re even having a cultural conversation about whether a generation has been destroyed because of the effects of smart devices. I don’t think it’s gone quite that far, but I hear constantly from parents about the difficulty they have trying to separate their kids from their screens. 

Now, I am an old-school Apple fan, using Apple computers and devices almost exclusively ever since my first experiences with an Apple II in elementary school. So it was with great interest that I saw the recent headlines about investors calling for Apple to look into how their technology may be harming kids and to mitigate any potential harms. Then, earlier this week, Farhad Manjoo went even further with an article in the New York Times about how Apple can help save all of us, adults included, from the attention-grabbing consequences of their technology by building a “less-addictive iPhone.” I agree with Manjoo that this represents a great opportunity for Apple, since their business model does not depend primarily on people using their devices nonstop. However, designing software to be less addictive for all is a much more complicated issue than putting in better parental controls for minors, so I’m going to focus on the latter for rest of this post.

Ultimately, I think the answer to the question posed in the title of this article is that parents are responsible for their kids, but parents need help, and Apple can do a lot more to make it easier for parents to set appropriate limits. Even for savvy parents who do not allow screens in bedrooms, sometimes the lure of the device is so tempting that a kid would sneak it into their rooms at night. Many parents I work with try to set screen time limits, but they can’t keep watch on their kids all the time, and it’s hard for a parent to know how much time a kid is spending watching videos vs. playing games vs. working on homework. And even when a parent can accurately track the time and tells a child to stop using the device, this often leads to arguments and fights if the child is super-engaged in what they’re doing (I probably see a biased sample of kids who tend to get very irritable when this happens). Plus, I’m sure that Apple can come up with a much more elegant solution than a lockbox with a timer

Most of us have probably heard by now that defaults matter, whether it’s for organ donation rates, food choices, or 401k participation. And right now the default when setting up a new iPhone or iPad is that the user is all-powerful; she can access all apps, all sites, and use the device at all hours of the day and night. Stricter controls have to be manually enabled, which many parents simply do not do. Also, Apple’s current parental controls (under Settings -> General -> Restrictions) are rudimentary: specific apps can be restricted, and if a child tries to download a new app from the App Store, parents can choose to get an alert on their device that would allow them to approve or deny the purchase. There is also a content filter for apps, movies, and music that restricts adult content, and a website filter that blocks access to adult sites.

This is not a bad start, but far from adequate in today’s environment. I think Apple should ask during the initial setup of a new device whether the device is intended for a minor, and if so, the age of the child. With that info, Apple should then set defaults (which the parent can always change later) that are age-appropiate, in line with expert recommendations on screen time, gaming, and how much sleep kids need. If a device is in “kid mode” and it runs up against preset time limits, it should give the user a warning 5 minutes and 1 minute before the time limit is reached, so there will not be any surprises when the user gets locked out of what they’re doing. The device should also lock itself 1 hour before bedtime. If the child wants to use it past a time restriction, the parent would have to grant permission on a case-by-case basis. 

Here’s an example of what I think might be roughly appropriate for 2 broad age groups:

Kids (6-12)
Video watching: 30 mins
Games: 30 mins
Nighttime: No use after 8pm
Apps: All apps (except Phone, Mail, Messages, Music, Photos) initially restricted; parents can manually enable other apps
Contacts: Only allow calls/texts/email with approved contacts
Content: Block adult content and websites

Teens (13-18)
Video watching: 1 hr
Games: 1 hr
Social media apps: 1 hr
Total use of above categories: 2 hrs
Nighttime: No use of most apps after 10pm, but can play music or podcasts
Apps, Contacts, Content: Less restrictive than for kids, but parents should have an easy way of seeing how much time is spent in different apps.

If you think I’m being too strict, then you probably haven’t been paying attention to how much tech industry executives tend to limit their children's access to devices. As I said on the Twitter:

I was encouraged recently when Apple took a step to look after for its users’ interests by requiring that game developers disclose the odds in games that have gambling-style mechanics. Up to now, Apple may have viewed parental control software as a third party opportunity, creating an opening for successful businesses like OurPact or Disney's Circle. But Apple also has a long tradition of “sherlocking,” in which they steal the best features of a third party product and incorporate them into their operating system. When it comes to setting better defaults for kids, I would encourage Apple to sherlock away!

Thursday, December 14, 2017

Euphoria At The Burger Joint

The line at the popular local burger joint was much shorter than usual when my fiancée and I arrived arrived with visions of freshly seared beef and milkshakes dancing in our heads. We couldn’t believe our luck: aside from the people currently ordering, there was only a middle-aged woman and a young couple standing in line in front of us. We didn’t notice anything amiss, at first.

Then I saw that the woman was not actually in line, but she was approaching the couple in front of us, apparently looking to strike up a conversation. Her hair was a bit unkempt, her make-up slightly excessive. And she was holding a thick wad of cash in one hand. She was beaming from ear to ear as she asked the couple in front of us, “Are you two on a date?”

“Yeah, it’s our first date,” said one member of the couple.

“How wonderful!” the woman exclaimed. “I can see love, and I can just tell that you two were meant to be together.”

The couple chuckled nervously, and the the woman started talking to them about the importance of Love in the Universe.

I watched what was happening in front of us with growing unease. I’ve seen this kind of irrational exuberance—and lack of boundaries—before during various psychiatric rotations, in patients who were manic or high. It usually didn’t end well. I noticed that my fiancée and I were standing closer together by now, and I glanced at her with a worried look that said, “What do we do?” She shot me a look back that said, “You’re the psychiatrist, you tell me!” We were both quite hungry, so leaving was out of the question. We stayed in line to await the inevitable.

Eventually, the woman held out a $20 bill to the male half of the couple and said, “Here, take this! I want to celebrate your beautiful young love!” As he reached for the money, the woman moved in closer, wrapping her arms around the guy and giving him a big kiss on the cheek. I think it would have been on his lips had he not turned his head at the last second. “Whoa!” he said, as he hastily backed away to free himself of her, with a new $20 bill in his hand.

Thoughts of worst-case scenarios crossed my mind. What if this lady got really agitated if we didn’t want to talk to her, or we didn’t want to take her money (or kiss her, for that matter)? I tried desperately to remember the brief training I got as a psychiatry resident on how to maintain a defensive stance when dealing with potentially aggressive patients. I stood a bit sideways to the woman, so my vulnerable belly was not as exposed. I kept my right foot, which was closer to her, pointed towards her and my weight on my left foot, in case I had to move in either direction. I crossed my arms and then pretended to stroke my chin with my right hand, so my arms would not be sitting uselessly by my side if I needed them.

Sure enough, the woman approached and asked us, “Are you on a date?”

I made sure not to look at her too directly as I mumbled, “Not really, just here for some burgers.”

Still, she held out a $20 and said, “Here, I have a present for you!” Not wanting to escalate the situation by saying no to her, I decided I might as well take it. I stuck my arm out as far as I could towards her, so that it would be more difficult for her to step closer for a smooch. I held my breath as she put the money in my hand and swiftly moved on to the next person in line behind me. “Whew,” I thought. “Guess that training really worked!”

As I looked at the $20 bill in my hand, I asked my fiancée, “What should we do with this?” Again, she would not let me off the hook. “You’re the one who took it, you decide!” I briefly debated paying for our meal with that money, but it just felt a little…crass. I paid with a credit card instead, and put the bill in my wallet. Once we got our food, I turned back towards the entrance to see what the woman was up to, but she had left, presumably to do good deeds elsewhere. I felt guilty, of course. It would certainly have been worse if she had been giving away Benjamins, but who knows what percentage of her personal savings she was wasting like this, one 20-dollar bill at a time?

But would it have made sense to call the police on her for causing a disturbance, or for sexual harassment, given her unwanted kissing? Even if they came, took it seriously, and hauled her to the nearest psychiatric ER, would there have been enough to involuntarily detain her? What if she had just won the lottery and was being very happy and generous?

Still, those burgers and shakes were tasty, and well worth the time spent standing in that particular line.

Readers, what do you think you would have done in this situation?

Saturday, December 9, 2017

My Free-to-Play Gaming Postmortem

So there was this period of time from mid-September 2015 to mid-October 2017 in which I didn’t write a single blog post. What happened? This post is my attempt to reflect on my hiatus from blogging.

The most convenient answer—and the one most friendly to my ego—is that I had simply gone through some Major Life Changes that got in the way of devoting time to this blog. However, if I dig deeper, I must admit to myself that October 2015 is when I started playing a free Japanese mobile game called Puzzle and Dragons (PAD), and October 2017 was when I started to get tired of playing it; I finally deleted the game from my phone last week.

Left: A random person's monster collection. Right: a monster card in all its glory.
The basic gist of PAD is that you assemble a team based on different “monster cards,” each of which has different properties. You obtain the best cards by spending “magic stones” on a Rare Egg Machine, which pops out a random monster card at a cost of 5 stones. The stones can be earned for free by beating levels in the game or purchased for $0.99 each (or only $59.99 for 85!). With your team, you fight your way through various dungeons, doing damage to the enemies based on how many orbs of the same color you can match in rows or columns of at least 3 on the game’s puzzle board. As with any decently fun game, it felt rewarding to finally beat a difficult level after multiple tries. And the artwork and graphics, hand-drawn by Japanese artists, were top-notch. But in addition to these basic features shared with most games, PAD has many mechanisms that increase its ability to grab ahold of players’ attention, time, and money, and these psychological manipulations are very clear for me to see in retrospect.

Left: Narrowly escaped death from the enemy's attack. Right: My team doing some serious damage to Kali.
The game frequently gives away magic stones and other goodies for free, using reciprocity to make a player feel motivated (or obligated) to keep playing. Also, you get more rewards the more consecutive days you log in, which helps players make the game a daily habit à la Snapstreaks. The most powerful cards, of course, are very rare, so there’s intermittent variable interval reinforcement when you get lucky and land a good card. There are special events every few weeks called “Godfests,” which are the only times players can get certain rare cards, creating some serious FoMO. Once you’ve invested time and energy to assemble a nice collection, there’s a strong tendency towards loss aversion, as no one wants to feel like they’ve wasted all this time for nothing. Since most of PAD’s players are young men, many of the most desirable cards feature scantily-clad female characters, a.k.a. “waifus.” And there’s a community aspect as well, with multiple forums devoted to the game where players share their accomplishments and good Godfest luck, leading to upward comparisons and social reinforcement.

Despite all that, I’m not sure I would say that I was addicted to the game in a clinical sense. I was spending ~30-60 minutes a day playing the game, and maybe another half hour a day reading about it. My personal relationships and work did not suffer, as far as I can tell. Over the course of 2 years, I spent a grand total of $10 on in-app purchases of magic stones. On PAD forums there are reports of “whales” who've spent upwards of thousands of dollars on the game, so I got off relatively easy, at least in a financial sense.

Still, how PAD affected my mind is undeniable. Instead of reading blogs related to psychiatry and mental health, I was reading blogs and watching YouTube channels related to PAD. I stopped even thinking about my blog, and every time I had a spare moment, I would open the PAD app instead of taking in my surroundings or reading a book. In fact, I read far fewer books in 2016 and 2017 compared to any other year in my life since I learned to read, though part of that may be due to reading more on the web. It wasn’t all bad, though. I wasted far less time on Twitter, and I was no longer waking up in the middle of the night with ideas for blog posts. I had a convenient and pleasant distraction from politics. And I’ve spent much less mental energy these last 2 years obsessing about my fantasy football teams than I have in previous years.

So what finally made me stop? A part of it was the fact that PAD’s creators are constantly adding more difficult dungeons, which in turn require ever more powerful (and rare) monster cards to deal with. Playing the game started to feel increasingly like a Sisyphean task. I’d also like to think that a part of me missed blogging and reading books. Recently, I came across the philosophically-oriented Slate Star Codex blog, written by a young psychiatrist, and I thought, “If he can write several 2000 to 5000-word blog posts in a week, then why can’t I be even 3% as productive (i.e. roughly a 1000-word post per month)?”

Lastly, some advice for parents out there: as fun as Super Mario Bros was for us in our youth, it does not remotely compare to the reinforcement mechanisms that today’s microtransaction-driven mobile games employ. I’ve heard multiple stories from parents about their kids stealing their credit cards to spend hundred of dollars on in-app purchases for games like Clash of Clans and Clash Royale. I now believe that parents should not be letting their kids play games like these, which all tend to use similar attention and money-grabbing tactics. As a general rule, this applies to any of the mobile games that you see advertised on TV; how else would those game companies have so much money to spend on prime time ad spots? Recently, regulators in The Netherlands have started investigating whether games that have “loot boxes” (a similar idea to the Rare Egg Machine) are a form of gambling and should be regulated as such. In my mind there is no doubt that these games can work very similarly to gambling, except you can’t actually win any money, so it’s in a way worse than gambling.

Even if there are kids who can responsibly play these games without spending too much time or money, I would still strongly suspect that these games have an outsized influence on what their players think about—and stop thinking about—even when they’re not playing. And for me, that was ultimately the biggest negative impact.