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.