When I learned of the controversy over Lisa Littman’s seminal paper from 2018, which introduced the concept of rapid onset gender dysphoria (ROGD), I did not understand the nature of the backlash. Littman’s paper appeared in a respected journal, PLOS One, and had passed through the peer-review process. Shortly after its publication, however, the dean of public health at Brown University, where Littman, a physician, worked, published a letter noting that the Brown community was concerned that “conclusions of the study could be used to discredit efforts to support transgender youth and invalidate perspectives of members of the transgender community.”
The letter also claimed that Littman’s research design and methods were problematic, despite her paper’s surviving an unusual post-publication assessment by senior journal editors, academic editors, a stats reviewer, and an expert reviewer. Littman claims that, after the post-publication review, her methods and findings were left virtually intact in a republished version of the paper. Most of the changes involved highlighting how her data were collected from parent reports and the limitations of those reports.
But the dean’s letter and the backlash to Littman’s paper suggest that critics’ real concern was Littman’s tentative conclusion suggesting the emergence of a novel developmental pathway to gender dysphoria. In her study, Littman hypothesized that a new form of gender dysphoria, and trans-identification, was presenting among peer groups of adolescent girls typically immersed in online trans subcultures and who often had preexisting mental health and developmental issues. Strikingly, most of these girls had no childhood history of gender dysphoria, or even gender nonconformity, and their newly announced identities seemed unexpected and caught their parents by surprise.
Littman speculated that gender dysphoria was becoming a catch-all interpretive framework for a range of phenomena, from normal pubertal angst to specific mental health issues. She also speculated that, among youth with existing mental health issues or unprocessed sexual trauma, a trans identity could serve as a maladaptive coping mechanism to avoid dealing with intense negative emotions. This notion was tentatively supported by her finding that 61.4 percent of parents surveyed reported that their trans-identifying children were easily “overwhelmed by strong emotions and go to great lengths to avoid experiencing them.”
Critics realized that Littman’s hypothesis directly challenged the tenets of gender-identity theory, which hold that people have a felt sense of gender that is both innate and immutable. That theory has become a central justification for hormonal and surgical body modification. Critics alleged that Littman’s method of surveying parents was unreliable, but Littman showed that her method was consistent with other papers that support “gender affirmation” and are widely accepted by the pro-affirming side.
Fast forward six years, and Littman’s academic critics seem more committed to their intellectual and ideological priors than pursuing truth. Their main argument against ROGD is that what appears to parents as the sudden onset of transgender identity is really a late disclosure of an identity that has existed since childhood, even if the adolescent hasn’t felt comfortable revealing it to family and friends.
In a recent letter to the editor published in the Archives of Sexual Behavior, the Manhattan Institute’s Leor Sapir, along with Lisa Littman and Michael Biggs, take on the latest iteration of this argument in a paper by researcher-activist Jack Turban and his colleagues. The paper, “Age of Realization and Disclosure of Gender Identity Among Transgender Adults,” purports to show evidence of the early-realization/late-disclosure explanation for the rise in ROGD. Sapir et al.’s letter not only indicts Turban et al.’s subpar research but also, by extension, the current state of academic publishing on matters pertaining to identity (exemplified by the “ethics guidance” released by the journal Nature Human Behaviour).
Turban et al.’s argument is based on responses from the 2015 U.S. Transgender Survey, the largest of its kind to date, with a total of 27,715 respondents. USTS-15 asked adult participants to recall—and as critics have pointed out, recall itself is notoriously unreliable—at what age they “first felt their gender was different from their assigned birth sex” and at what age they “started to think they were trans (even if they did not know the word for it).” Turban and his coauthors took the answer to the first question rather than the second as the moment respondents first “realized they were transgender” and assessed the median time between realization and the disclosure of the identity to others. They divided participants into an “early realization” group (age ten or younger) and a “late realization” group (11 or older). Because a key premise of ROGD is that a trans identity develops rapidly within the context of adolescence, if the Turban study could show that a trans identity developed in childhood but was only disclosed later, it would undermine the ROGD hypothesis.
Yet, Turban and his colleagues seem uninterested in rigorously testing the ROGD hypothesis. Well-known for his mischaracterization of existing research, Turban made interpretive choices that strongly suggest he and his coauthors were avoiding any USTS-15 data that might undermine their broadside against ROGD.
Sapir et al.’s response is worth reading in full, but some examples of their findings should suffice here. First, to be eligible to participate in USTS-15, respondents had to identify currently as transgender. By definition, this means that anyone who identified as trans as adolescents but no longer did so as adults was excluded. Since this excluded group may include individuals whose dysphoria presentations match the ROGD phenomena, the USTS-15 sample is highly biased against ROGD hypothesis testing. Amazingly, Turban and another coauthor pointed out this limitation of the sample in a previous paper they published. Here, however, they simply ignore it.
Second, the ROGD phenomenon is hypothesized as an emergent phenomenon among a cohort of trans-identifying youth who came of age in the late 2000s or later—intersecting with widespread changes in social media, phone use, and the rise of the transgender social movement—which means that the phenomena would apply only to the 18–24 age group of the USTS-15. Despite this, Turban & colleagues analyzed the time period from realization to disclosure for the entire adult sample, and then only for those who said that they had early realization (age 10 or younger)—meaning not the cohort that would be relevant to ROGD.
Third, Turban and his coauthors chose as their proxy for age of realization a question put to participants about their age when they “felt that their gender was different from their birth sex”—instead of another question that asked them “at what age they first thought they were trans.” Asking people about their gender is more nebulous and less precise than asking them when they first thought they were trans. Not least, the problem of recall bias means that adult respondents—who, in this case, were recruited through transgender advocacy networks—could retroactively interpret reasons for “feeling different” through a gendered lens. In short, “feeling different” is a less reliable proxy for “realization” than an explicit question about the adoption of a transgender identity.
Turban et al. don’t explain this interpretive choice, but one suspects the reason: it produces a longer time from realization to disclosure. Because they take respondents’ answers about when they first “felt different” (which they code as “realized they are transgender”) at face value, they are left defending the absurd proposition that hundreds of USTS-15 respondents realized that they were transgender before their second birthday.
As Sapir’s letter notes, had the researchers analyzed data for the precise measure, they would have found that nearly 75 percent of the total sample reported late realization of a trans identity, compared with 40.8 percent originally reported. Moreover, data analyzed for the precise measure in the ROGD 18–24-year-old cohort reveals participants reported 83 percent late realization and only 17 percent early realization.
Of central importance, Turban and his coauthors claim to find that the median time from realization to disclosure was 11 years and the mode was 13 years. Had they analyzed the correct group (“late realization”), they would have found that both males and females had a mode of one year and a median of three years. In a follow-up reply to critics, Sapir and Littman point out that 2,127 respondents to the USTS-15 said that they went from “first feeling different” to disclosing a transgender identity to others in one year or less. The number of respondents who went from “first feeling they are transgender” to disclosing that identity to others within the same timeframe was 3,685. The denominator here (all 18–24-year-old respondents) was 5,880, which means that the data source Turban et al. themselves chose as reliable for testing ROGD shows that between one-third (if we’re being generous to Turban) and two-thirds (if we’re taking respondents’ report of “realizing they are transgender” at face value) meet the criteria for “rapid” development of transgender identity.
Additional features obscured in the Turban analysis also support the ROGD hypothesis. For example, ROGD is hypothesized to affect women more than men due to greater susceptibility to peer influence and because of the documented mental health crisis among girls. While the Turban paper reports that 63.2 percent of the late-realization group was female, that percentage increases to 75.2 percent if only the relevant 18-24-year-old cohort is analyzed. Relatedly, data from the 18-24-year-old cohort also reveals that the younger cohort reported more psychological distress than older cohorts—lending more support to the ROGD hypothesis that trans-identification is a coping mechanism for preexisting psychological distress. This is consistent with research suggesting that comorbidities predate trans identification in this cohort.
Taken together, it is hard to see Turban et al.’s paper as anything but a sloppily engineered effort to discredit a hypothesis the authors disagree with for political reasons. That the Journal of Adolescent Health published their paper is yet more evidence of the ideological capture of medical journals. To add insult to injury, Sapir posted a thread on Twitter regarding his letter to the editor and tagged the Journal of Adolescent Health, which promptly blocked him. This is behavior befitting a moody teenager, not the managers of a medical journal’s social media account.
