A statement was just released by the Coalition for the Advancement & Application of Psychological Science (CAAPS), calling for the elimination of the use of Rapid-Onset Gender Dysphoria (ROGD), “given the lack of rigorous empirical support for its existence.” CAAPS is an umbrella organization of other psychology associations with the expressed purpose of promoting evidence-based practice, and their full ROGD statement is available here.
Despite the mission of the organization, CAAPS’ statement not only failed to arrive at the scientifically correct answer, but also it failed even to ask the correct scientific question. The question has never been (and isn’t supposed to be) whether ROGD exists: The question is whether the recent and explosive increase in trans referrals being reported across the world (e.g., de Graaf et al., 2018; Frisén et al., 2017; Kaltialo-Heino et al., 2020; Wood et al., 2013) represents one of the previously well-characterized profiles of trans people (so we would know what to do) or something new (wherein we can’t).
The available evidence suggests it is something new: These people are quite dissimilar from previous groups on multiple objective variables, including age of onset, sex ratio, and comorbid mental health issues (Aitken et al., 2015; Ashley, 2019; Becker et al., 2014; Kaltiala-Heino et al., 2015; Littman, 2018; Wood et al., 2013). That is, we cannot merely assume that the outcomes research from the already known trans profiles applies to this one. Despite some initial indication of improvement on some variables after transition for adolescents (de Vries et al., 2011), such benefits have largely failed to replicate, despite multiple attempts, instead emerging as a general lack of improvement relative to controls (e.g., Achille et al., 2020; Carmichael et al., 2021; Costa et al., 2015; Kuper et al., 2020; van der Miesen et al., 2020). The researchers repeatedly concluded that “[M]ost predictors did not reach statistical significance” (Achille et al., 2020, p. 3, italics added) and “The present study can, therefore, not provide evidence about the direct benefits of puberty suppression overtime and long-term mental health outcomes” (van der Miesen et al., 2020, p. 703, italics added). Indeed, even de Vries’ original report of improvement was only mixed—although improved on some variables, the sample worsened on others, including on body satisfaction. Notably, another claim of improvement (Bränström & Pachankis, 2019) was withdrawn after its statistical errors were identified and its data re-analyzed (Kalin, 2020). One of the authors of that now retracted finding (Pachankis) is one of the two people whom CAAPS’ offers as media spokespersons for GLBTQ+ issues (full list here).
Scientifically, it doesn’t actually matter if ROGD exists as CAAPS considers: What matters is whether and what kinds of transition benefit the people fitting this profile, which we cannot know. To declare that ROGD doesn’t exist without pointing this out, however, is to recommend treating ROGD as if it were ‘regular’ gender dysphoria by default, despite that we already know the people fitting the ROGD profile significantly differ from the samples represented in the gender dysphoria outcomes research. One cannot conduct the ethical task of a risk:benefit ratio while lacking knowledge of the latter.
It is quite plausible that ROGD doesn’t exist as a gender dysphoria. “ROGD” is only a shorthand description of the most salient feature by which people with this profile differ from the known profiles (they lack a childhood history of gender dysphoria; Littman, 2018). I suspect very many such cases will turn out to be better helped if treated as manifestations of other, already known phenomena, such as Borderline Personality Disorder (which includes identity disturbance and unstable self-image) or an autism spectrum disorder. Such was largely the case with ‘Recovered Memory Syndrome’: In an era when cases of child sexual abuse were finally receiving overdue attention, other people with unhealthy needs for attention began claiming the same, and credulous clinicians failed to challenge clients, instead becoming enablers of the unhealthy bids for attention.
Lacking from CAAPS’ statement was any indication of what might falsify their belief: On how many (more) objective—i.e., non-self-report—variables do differences have to be demonstrated before we can treat ROGD as a different phenomenon from previous groups of trans people? How many (more) failures to replicate evidence of benefit to transitioning for this new profile would merit a slow-down to transition-on-demand for the people showing it?
None of this should be taken at all to be denying/dismissing people’s reports of dysphoria or distress. Rather, I point out (by way of analogy) that clinicians need to do different things to help people with major depression vs. bipolar depression vs. postnatal depression, despite that they can feel similar and would be described similarly. Although we do not yet have enough evidence to tell us exactly what ROGD is, we do have sufficient evidence to know what it is not. Treating this demonstrably new presentation the same as the known ones is to declare, ‘They all look alike to me.’
Achille, C., Taggart, T., Eaton, N. R., Osipoff, J., Tafuri, K., Lane, A., & Wilson, T. A. (2020). Longitudinal impact of gender-affirming endocrine intervention on the mental health and well-being of transgender youths: Preliminary results. International Journal of Pediatric Endocrinology. doi: 10.1186/s13633-020-00078-2
Aitken, M., Steensma, T. D., Blanchard, R., VanderLaan, D. P., Wood, H., Fuentes, A. … Zucker, K. J. (2015). Evidence for an altered sex ratio in clinic-referred adolescents with gender dysphoria. Journal of Sexual Medicine, 12, 756–763.
Ashley, F. (2019). Shifts in assigned sex ratios at gender identity clinics likely reflect changes in referral patterns [Letter to the Editor]. Journal of Sexual Medicine, 16, 948–949.
Becker, I., Gjergji-Lama, V., Romer G., & Möller, B. (2014). Characteristics of children and adolescents with gender dysphoria referred to the Hamburg Gender Identity Clinic [German]. Prax Kinderpsychol Kinderpsychiatr, 63, 486–509.
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Frisén, L., Söder, O., & Rydelius, P. A. (2017). [Dramatic increase of gender dysphoria in youth]. Lakartidningen. Retrieved from http://lakartidningen.se/Klinik-och-vetenskap/Klinisk-oversikt/2017/02/Kraftig-okning-av-konsdysfori-bland-barn-och-unga/.
Kalin, N. H. (2020). Reassessing mental health treatment utilization reduction in transgender individuals after gender-affirming surgeries: A comment by the Editor on the process. American Journal of Psychiatry, 177, 765.
Kaltiala-Heino, R., Sumia, M., Työläjärvi, M., & Lindberg, N. (2015). Two years of gender identity service for minors: Overrepresentation of natal girls with severe problems in adolescent development. Child and Adolescent Psychiatry and Mental Health, 9, 9.
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Kuper, L. E., Stewart, S., Preston, S., Lau, M., & Lopez, X. (2020). Body dissatisfaction and mental health outcomes of youth on gender- affirming hormone therapy. Pediatrics, 145, e20193006.
Littman, L. (2018). Parent reports of adolescents and young adults perceived to show signs of a raid onset of gender dysphoria. PLoS ONE, 13(8), e0202330.
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Wood, H., Sasaki, S., Bradley, S. J., Singh, D., Fantus, S., Owen-Anderson, A., … Zucker, K. J. (2013). Patterns of referral to a gender identity service for children and adolescent (1976–2011): Age, sex ratio, and sexual orientation [Letter to the Editor]. Journal of Sex and Marital Therapy, 39, 1–6.