What is Rapid Onset Gender Dysphoria?

What is Rapid Onset Gender Dysphoria?
August 29, 2018

A recent study of Rapid Onset Gender Dysphoria—the first of its kind—has created waves across the internet. Some transgender activists are outraged over it; others on the political right are using it to criticize the political left; still others, who don’t have a bone in the fight, are interested in further exploring and testing the findings. In this post, I want to summarize the study and then offer four things that Christians should consider as a result of its findings.


Rapid Onset Gender Dysphoria (ROGD) “describes a phenomenon where the development of gender dysphoria is observed to begin suddenly during or after puberty in an adolescent or young adult who would not have met criteria for gender dysphoria in childhood” (Littman, p. 2). Most people who experience gender dysphoria show signs of wanting to be the opposite sex or exhibit cross-gender behavior as early as three or four years old; the term for this is Early Onset Gender Dysphoria. But, according to the study, those who experience ROGD typically do not show signs of cross-gender behavior, or a desire to be the opposite sex, as a child. Rather, their gender dysphoria seemed to come out of nowhere during or after puberty, and—this is where the controversy gets heated—their dysphoria and desire to identify as trans might be correlated with, and possibly shaped by, social and peer influences.


The author of the study, Dr. Lisa Littman, is a physician, a researcher, and an assistant professor at Brown University. Her article is the first peer-reviewed study of ROGD—a phrase she coined back in 2016. The study consisted of 256 parents who reported that their kids experience ROGD. The parents completed a 90-question survey, along with open text questions that allowed the parent to add additional comments.


While the study has been labelled anti-trans and transphobic by some of its critics, it’s important to note that 86% of the study’s participants support same-sex marriage and 88% believe that “transgender people deserve the same rights and protections as others” (p. 6). Dr. Littman herself believes that some transgender people “would benefit from transition” (p. 34) and gives no evidence whatsoever in the study that she is even mildly transphobic or unsupportive of transgender rights. And, as a professor at Brown University, it’s very unlikely that Dr. Littman is a closet conservative with an anti-LGBTQ agenda. (Brown University just removed their own news report of the study due to “questions raised about research design and data collection.”) From my reading of the study, Dr. Littman gives every impression that she’s an honest researcher who’s interested in the complexity of human behavior and willing to follow the evidence where it leads.


There are several noteworthy observations that stand out from the study. First, an overwhelming majority of the kids with ROGD were natal females (83%), which matches the substantial increase in natal females seeking care from gender clinics (p. 31). This is remarkable since it was predominately natal males who previously were the ones seeking care for gender dysphoria. Littman explores the possibility that ROGD “may have some similarities to anorexia nervosa and the characteristics that make female adolescents more susceptible than male adolescents to anorexia nervosa may be the same characteristics that make natal females more susceptible than natal males to rapid-onset gender dysphoria” (p. 31, cf. 3-4).


Second, those who experience ROGD did not show signs of cross-gender behavior as pre-adolescents. As their parents often said, their “announcement (that they were transgender) came from ‘out of the blue’” (p. 13). Critics of the study have rightly pushed back on this, however. “Parent reports of a ‘rapid’ onset of dysphoria are especially questionable,” writes Zinnia Jones. “Many trans youth understandably conceal their identities for years, knowing the consequences of coming out to potentially unaccepting parents could be dire.” This is a valid critique and parents of ROGD kids should evaluate whether they are creating and nurturing safe environments where their kids can talk openly and honestly about their dysphoria—or anything else they’re wrestling with in life. However, this sort of critique fails to consider the fact that 5 of the 8 criteria for diagnosing gender dysphoria are “readily observable behaviors and preferences” (p. 8)—stuff parents could see, even if the child didn’t feel comfortable talking to their parents about it. According to the DSM-5, a child must meet at least 6 out of the following 8 criteria (the first one has to be met) to be diagnosed with gender dysphoria:

Gender Dysphoria in Children                                     302.6 (F64.2)
  1. A marked incongruence between one's experienced/expressed gender and assigned gender, of at least 6 month's duration, as manifested by at least six of the following (one of which must be Criterion A 1):
    1. A strong desire to be of the other gender or an insistence that one is the other gender (or some alternative gender different from one’s assigned gender).
    2. In boys (assigned gender), a strong preference for cross-dressing or simulating female attire; or in girls (assigned gender), a strong preference for wearing only typical masculine clothing and a strong resistance to the wearing of typical feminine clothing.
    3. A strong preference for cross-gender roles in make-believe play or fantasy play.
    4. A strong preference for the toys, games, or activities stereotypically used or engaged in by the other gender.
    5. A strong preference for playmates of the other gender.
    6. In boys (assigned gender), a strong rejection of typically masculine toys, games and activities and a strong avoidance of rough-and-tumble play; or in girls (assigned gender), a strong rejection of typically feminine toys, games and activities.
    7. A strong dislike for one’s sexual anatomy.
    8. A strong desire for the primary and/or secondary sex characteristics that match one’s experienced gender.
  2. The condition is associated with clinically significant distress or impairment in social, school, or other important areas of functioning. 


Notice that criteria 2-6 are readily observable by parents, even if the child doesn’t feel comfortable talking about 1, 7, or 8 with their parents later on. The fact that the gender dysphoria appeared “out of the blue” probably wasn’t because their kids simply hid it from their unaccepting and “transphobic” parents, as some critics suggest.


Third, in most cases, the ROGD appeared to be strongly associated with “peer contagion,” which “is the process where an individual and peer mutually influence each other in a way that promotes emotions and behaviors that can potentially undermine their own development or harm others” (p. 3). Several pieces of evidence from the study suggest that social and peer contagion played at least some role in their ROGD and transgender identity.


  • 44% came out as transgender after 1 of their friends did; 28% after 2 of their friends did, 15% after 3 of their friends did, 4% after 4 of their friends did, and 5% after 5 of their friends did.
  • 64% of parents report an increase in social media use that focused on transgender related topics. Littman (p. 19) summarizes the advice their received online:
    • how to tell if they were transgender (54%)
    • the reasons that they should transition right away (35%)
    • that if their parents did not agree for them to take hormones that the parents were “abusive” and “transphobic” (34%)
    • that if they waited to transition they would regret it (29%)
    • what to say and what not to say to a doctor or therapist in order to convince them to provide hormones (22%)
    • that if their parents were reluctant to take them for hormones that they should use the “suicide narrative” to convince them (21%)
    • that it is acceptable to lie or withhold information about one’s medical or psychological history from a doctor or therapist in order to get hormones/get hormones faster (18%).


Some might pushback against the “peer/social contagion” theory, since coming out as trans would decrease acceptance and popularity and increase the chance at being bullied and harassed at school. Why would anyone want to come out as trans if they weren’t really trans?  This is certainly the case in some schools, and would certainly be true in most schools 5 or 10 years ago. But one of the most striking observations the parents made was that their kids’ new identity as trans increased popularity, friends, acceptance, and even led to more protection against bullying. According to Littman, “Parents described intense group dynamics where friend groups praised and supported people who were transgender-identified and ridiculed and maligned non-transgender people” (p. 16). More than 60% of the kids with ROGD “experienced an increased popularity within their friend group when they announced a transgender-identification” (p. 16). One parent said that once her child came out “she became untouchable in terms of bullying in school as teachers who ignored homophobic bullying…are now all at pains to be hot on the heels of any trans bullying” (p. 17). Other parents reported “improved protection from ongoing bullying” and “great increase in popularity among the student body at large” (p. 17).


Likewise: “to not be trans one would not have been included in his group” (p. 17). The popularity of identifying as transgender was coupled with a strong disdain for non-transgender people, especially white, straight males. “The groups targeted for mocking by the friend groups are often heterosexual (straight) people and non-transgender people…Sometimes animosity was also directed towards males, white people, gay and lesbian (non-transgender) people, aromantic and asexual people, and ‘terfs’” (p. 17). One participant reported:


In general, cis-gendered people are considered evil and unsupportive, regardless of their actual views on the optic. To be heterosexual, comfortable with the gender you were assigned at birth, and non-minority places you in the ‘most evil’ of categories with this group of friends. Statement of opinions by the evil cis-gendered population are considered phobic and discriminatory and are generally discounted as unenlightened” (p. 17).   


In the end, there’s seems to be some amount of social and peer contagion that’s correlated with ROGD and please some role in shaping it; however, the study doesn’t show (and doesn’t claim to show) that such contagion is the sole cause of ROGD. Further study needs to be done to further explore the relationship between peer contagion and ROGD—something Dr. Littman readily admits.


Fourth, a majority of ROGD kids (63%) also “had one or more diagnoses of a psychiatric disorder or neurodevelopmental disability preceding the onset of gender dysphoria” (p. 10). For instance:


  • 48% had experienced a traumatic or stressful event prior to the onset of their gender dysphoria
  • 45% were engaging in non-suicidal self-injury prior to the dysphoria
  • 15% had been diagnosed with ADHD
  • 12% were diagnosed as OCD
  • 12% were diagnosed on the Autism Spectrum Disorder
  • 7% had an eating disorder
  • 7% were Bipolar


Again, all of these mental health concerns were evident before the child exhibited any diagnosable signs of experiencing gender dysphoria. This is important, because some critics argue that these mental health issues are a result of trans people being shamed and rejected by their family and friends. It’s certainly true that many transgender people have experienced such bullying and rejection. But such was not the experience of the kids with ROGD in this study. These mental health issues were present before they came out as trans (or even showed any signs of gender dysphoria) and after they came out, they experienced (for the most part) an increase in social acceptance, popularity, and protection from bullying.


What’s perhaps most shocking is that of the ones who consulted a gender therapist, gender clinic, or a physician for the purpose of pursuing transition, only 28% of the clinicians bothered to “explore issue of mental health, previous trauma, or any alternative causes of gender dysphoria before proceeding”—even after the parents informed the clinician of such previously diagnosed mental health issues (p. 24). One parent “tried to give our son’s trans doctor a medical history of our son” but “she refused to accept it. She said the half hour diagnosis in her office with him was sufficient” (p. 26). Parents were often called “transphobic” or “bigoted” by their kids if they suggested that their child wait longer before they transition, or if the parent recommended a comprehensive health evaluation before transitioning, or simply expressed some concerns about transitioning (p. 21). Littman says that the majority of ROGD kids think that “transition would solve their problems” and many of them “became unwilling to work on their basic mental health issues before seeking treatment” (p. 33).  


In the end, Littman cautions the reader not to take her research in a direction that it’s not intended to go:


This research does not imply that no AYAs (adolescent young adult) who become transgender-identified during their adolescent your young adult years had earlier symptoms nor does it imply that no AYAs would ultimately benefit from transition. Rather, it suggests that not all AYAs presenting at these vulnerable ages are correct in their self-assessment of the cause of their symptoms; some may be employing a drive to transition as a maladaptive coping mechanism; and that careful evaluation is essential to protect patients from the clinical harms of overtreatment and under treatment (p. 37).


What should Christians walk away with from this study? I’ll offer four points of advice.


First, hold the conclusions of this study with an open hand. It’s the first study of its kind, and any thoughtful person should eagerly await several more studies before forming firmer conclusions about ROGD.


Second, even if everything in the study is true, this does not at all mean that most, or even many, transgender persons are identifying as such out of “peer/social contagion.” Littman was very clear that ROGD is a subset of a much larger umbrella of gender dysphoria. Don’t take her conclusions and apply them to all transgender people.


Third, the parent testimonies about some gender clinicians and trends happening at school should be concerning. While I’m not an advocate of culture warrior Christianity, parents should be concerned about the potentially destructive ideologies that our kids are swimming in. Yes, it is possible for a teenager to be socially pressured into identifying as trans and ultimately pursuing sex reassignment surgery and later regretting it. It’s politically incorrect to say this. It’s dishonest to deny it.


Fourth, the study further validates the truth that transgender experiences and identities are not all the same. When your son or daughter comes out as trans, or someone in your church wants to transition, or when we meet our neighbor who identifies as, say, non-binary or gender queer, the best way to truly know what this means is to get to know them. (Reading broadly on the topic doesn’t hurt either.) Listen to them. Hear their story. Find out what makes them happy and sad, fearful and courageous, hopeful and discouraged. What one transgender loved one will need from you might be very different from what another one needs from you. As my friend Mark Yarhouse likes to say, “if you’ve met one transgender person, you’ve met…one transgender person.” 


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Here are some related articles for further study:


Supportive of the concept of ROGD


Critical of the concept of ROGD