09 August 2021

CAAPS, ROGD, and the science neglected

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.’

Updated 16-Aug-2021

References

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.

Bränström, R., & Pachankis, J. E. (2019). Reduction in mental health treatment utilization among transgender individuals after gender-affirming surgeries: A total population study. American Journal of Psychiatry, 177, 727–734.

Carmichael, P., Butler, G., Masic, U., Cole, T. J., De Stavola, B. L., Davidson, S., Skageberg, E. M., Khadr, S., & Viner, R. M. (2021). Short-term outcomes of pubertal suppression in a selected cohort of 12 to 15 year old young people with persistent gender dysphoria in the UK. PLosONE, 16(2): e0243894.

Costa, R., Dunsford, M., Skagerberg, E., Holt V., Carmichael, P., & Colizzi, M. (2015). Psychological support, puberty suppression, and psychosocial functioning in adolescents with gender dysphoria. Journal of Sexual Medicine, 12, 2206–2214.

de Graaf, N. M., Giovanardi, G., Zitz, C., & Carmichael, P. (2018). Sex ratio in children and adolescent referred to the Gender Identity Development Services in the UK (2009–2016) [Letter to the Editor]. Archives of Sexual Behavior, 47, 1301–1304. 

de Vries, A. L. C., Steensma, T. D., Doreleijers, T. A. H., & Cohen-Kettenis, P. T. (2011). Puberty suppression in adolescents with gender identity disorder: A prospective follow-up study. Journal of Sexual Medicine, 8, 2276–2283.

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.

Kaltialo-Heino, R., Carmichael, P., de Graaf, N., Rischel, K., Frisén, L., Suomalainen, L., & Wahre, A. (2020). Time trends in referrals to child and adolescent gender identity services: A study in four Nordic countries and the UK. Nordic Journal of Psychiatry, 74, 40–44. 

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.

van der Miesen, A. I. R., Steensma, T. D., de Vries, A. L. C., Bos, H., & Popma, A. (2020). Psychological functioning in transgender adolescence before and after gender-affirmative care compared with cisgender general population peers. Journal of Adolescent Health, 66, 699–704.

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.

4 comments:

  1. Thnak you James
    As a mature student counsellor I was rather panicked about the AFFRIM protocols being used here in South Africa. I diversion from the real problmes the youth here face. Poverty and unemployment. Having tried to speak up at my college I was thoroughly disillusioned with psychology on its true intent in cousneliing. We were told by one tutor to be "activists" for Affirm! Insanity. I am supporting the IAPC and Ayanay who revert to original ethics in counselling psychology.

    ReplyDelete
  2. I wonder. Back when I was growing up, very few knew anything about GID. Let’s say you are going to purchase a new car. You look at all major makes but none are very appealing within your price range. You buy what you think is the best of a bad lot. A month or so after, you see a car you have never seen before. It is just what you wanted and even lower in price than what you paid for your new car. If you had known about it, there is no doubt in your mind that you would have bought the newly discovered car.
    I believe that partially explains the new catigory. Until the mid nineties, many of those in their late 30s, 40s, and 50s may not have known much, if anything, about transition. They did not read about it and if they saw a headline, it was brushed off as something so difficult, so outlandish, so impossible that no steps were taken. But children move away, deaths and divorce happen to the best of people, people move to new places where they know not a soul. Then, suddenly, “trans” becomes a known, with books, novels, magazine articles, and television dramas and a host of documentaries. As a Trans moves from the fringe to closer to mainstream, information becomes available - all sorts of explanations, guides, availability, and more are now commonplace. Compare the number of trans related books, both nonfiction and fiction before 1985 with the same numbers now. Up to the 1980’s the movie “I Want What I Want” was the only mainstream movie to deal with transsexuality. Now you could binge watch for a week. Today Trans becomes a recognized minority if still a persecuted minority, like non-white minorities. Laws are even changed to help with changes tof ID and more. The unknown has become known concurrent perhaps with life changes that remove impediments to transition.
    So those who would never have had the slightest interest are now exploring with much more information available.
    Now in their forties and with more information available, the removal of negatives and naysayers, the now visible Trans in many places which before would have excluded them, and a more accepting society, the idea once rooted can grow. As with many aspects of life, the more one knows the less frightened of problems and consequences one becomes. In my day, the support came over the Internet. Now, even in high schools and universities, trans peer support is accessible in ways not possible in earlier days.
    So! In my opinion, the increase is not something new or a new category. Rather, it is a manifestation of changes in society
    So, you like that car so much you trade in the car you bought as the best of a bad lot to buy the car you did not know even existed when you were in the market.

    ReplyDelete
    Replies
    1. If this theory you present was plausible, the massive rise in ROGD would be seen in all age groups and in both sexes. This has not been the case. The several thousand percent increase in cases of ROGD has been observed in the demography of young teenage girls. Not people in their forties or fifties. Hence the concern that other factors may be in play here. How would you explain that the phenomenon of ROGD is mostly isolated to this cohort? Shouldn't this at least be investigated before commitment to an all affirming model? The treatment, hormone replacements and surgical altering of the body, may lead to irreversible damage after all, if the patient would turn out to suffer from something else and regret the treatment they've been given. As has already been observed in some cases.

      Delete
  3. This comment has been removed by a blog administrator.

    ReplyDelete