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A Brief Commentary on Dr. Littman’s Response to Dr. Restar

By: L

Questions or comments for the author can be directed to Health Liberation Now! here.

There has been much written about Dr. Lisa Littman’s supposed identification of a “rapid-onset gender dysphoria” (ROGD) phenomenon and the subsequent use of the term by anti-trans groups to justify restricting access to gender-affirming care for transgender adolescents. Something which has gotten less attention is the post-correction defense that Littman published in 2020[1] of her original paper,[2] in which she responded to one particular critique made by Dr. Arjee Restar.[3] However, given that the criticisms Littman responded to in this paper overlap some with the concerns I raised in my own recently posed questions to Littman, I felt it would be helpful to highlight some points that she makes here and where they fall short. As in the questions that we sent to Littman, my analysis focuses on Littman’s interpretation and presentation of her work; the debate around its scientific merit is more or less a dead horse.

Inaccurately Representing the Affirmative Model

To begin her response, Littman speculates that so many professional organizations may have urged caution on her hypothesis due to a desire to defend the gender-affirmative model of care (GAMC) of trans children and adolescents (why they should be so invested in it is left as an exercise for the reader). Littman defines the affirmative model as “…an approach where once a person expresses a gender identity, regardless of their age, that identity is validated without delay or questioning why or how they arrived at that conclusion. Then social, medical, and surgical interventions are made available in accordance with several existing protocols”.[1, para. 3] Here, Littman omits the fact that the very same protocols she alludes to often recommend assessment – so, questioning and discussion of gender transition – before medical interventions. As examples of such protocols:

  • When the response was published, WPATH recommended that “[t]he adolescent has demonstrated a long-lasting and intense pattern of gender nonconformity or gender dysphoria” prior to initiating even reversible pubertal suppression.[4]
  • The current draft of WPATH’s soon-to-be-published Standards of Care Version 8 recommends “well-documented” dysphoria over “several years” and a “comprehensive assessment” prior to beginning gender affirming hormones.[5, as cited in International Transgender Health Group]
  • The Endocrine Society suggests that adolescents undergo cross-sex hormone treatment only after “a multidisciplinary team…has confirmed the persistence of GD/gender incongruence”.[6]

To give Littman the benefit of the doubt: some trans advocates advocate for granting youth greater autonomy and have argued against using such diagnostic requirements to determine which adolescents can access care.[7] However, the matter at hand is whether the major medical organizations Littman refers to support making medical interventions available “without question,” and the above sample protocols demonstrate that they do not. In particular, WPATH is one of the organizations that issued a cautionary response to her original paper.[8] Thus, portraying the broader medical profession – including those who criticized the original ROGD paper – as putting trans adolescents on a pathway to hormones and surgery without any thought beforehand is inaccurate at best and disingenuous at worst. It is particularly absurd given the well-documented barriers that exist for trans youth to access care, which include scarcity of qualified physicians, stigma, and financial barriers.[9]

Leaving out Context Surrounding the Criticism of Littman (2018)

When Littman portrays the scientific organizations which issued cautionary statements on her paper as solely seeking to defend the affirmative model, Littman also does not acknowledge the public reception of her paper. Immediately after Littman’s study was published, there was an explosion of interest in her research from right wing/Christian fundamentalist and transphobic “feminist” or “gender critical” groups. As a result, there are numerous parent groups which haphazardly apply the ROGD label to their children[10, 11] and seminars held by supposedly evidence-based advocacy groups about ROGD[12] who then leverage it to launch self-promotional international awareness day campaigns.[13, 14]

When it comes to reception, none of the other papers Littman cites even approaches the impact of ROGD on the trans healthcare debate. At the time of writing there are no websites, hashtags, or international awareness days about Surviving a gender-variant childhood: The views of transgender adults on the needs of gender-variant children and their parents, or Suicide risk in trans populations: an application of minority stress theory (although these are important topics and there should be). If anything, the mainstream media has been quite silent on the topic of trans healthcare, even in the face of an unprecedented, nationwide, right-wing assault on trans youth rights.[15, 16]

Given the ways in which science has been and continues to be used for the worse, it is not surprising that when one paper receives outsize attention, major medical organizations would issue statements advising caution on its findings. By omitting the circumstances under which the bodies issued their statements – that is, widespread and frivolous use of the paper by anti-trans organizations, which continues to the present – Littman both misrepresents her critics and absolves herself of responsibility for the ways in which her research has the potential to be misused.

Unevidenced Speculation as to Future Results

As opposed to the fact that major health organizations were opposed to the use of Littman (2018) to lobby in favor of conversion therapy and bans on transition-related healthcare, Littman asserts that they critiqued her paper because

If what has preliminarily been referred to as rapid onset gender dysphoria (ROGD) represents a new developmental pathway to gender dysphoria and transgender identification, one where psychosocial factors including social influence, trauma, homophobia, maladaptive coping mechanisms, and psychiatric disorders are contributing factors or even causal to identifying as transgender, it would disprove the premise that psychological issues can only be responses to negative experiences, not intrinsic to the process. If it is confirmed that one population of gender dysphoric individuals is harmed by approaches that affirm gender identity without questioning and benefits from extended clinical assessment (Clarke & Spiliadis, 2019) and a gender exploratory model (GEM) approach (Spiliadis, 2019), the evaluation process for gender dysphoric patients would become far more complex. If it is confirmed that there is a population of gender dysphoric individuals for whom the risks of social, medical, and surgical transition usually exceed the benefits, it would undermine another GAMC assumption.[1, para. 5]

Littman uses these conditionals to claim that Littman (2018) challenges the GAMC. However, to quote the astronomer and popularizer of science Carl Sagan: extraordinary claims require extraordinary evidence.[17] I will add that this especially applies when the extraordinary claim contradicts an existing scientific consensus, in this case that trans identity can become apparent at any age.[18] Even if the evidence that Littman provided was completely flawless, it only would have been one paper that could be interpreted as evidence against the GAMC. Many studies confirming the benefits of appropriate medical intervention for adolescents collectively are used to justify the GAMC.[19, 20] Thus, acting as if the findings of Littman (2018) meaningfully threaten the GAMC because future research might back them up is scientifically unfounded and ignores the existing body of research in favor of the GAMC. By this logic, the fact that a few people have experienced adverse effects from the COVID-19 vaccine and the possibility that research in the future might discover more vaccine risks could be used to justify asking whether some people should get vaccinated at all. Get your shots!

Lack of Follow-Through on Future Research

So, what would it take to really undermine the GAMC in the way that Littman believes her original study did? As a first step to confirm ROGD as a real phenomenon, writer and biologist Julia Serano asks:

Rather than offering mere speculation and hypotheses, show me that there is some specific reproducible cause of gender dysphoria in “ROGD kids” that is largely or completely absent from kids who experience regular old gender dysphoria. Or show me that kids who are deemed ROGD exhibit an entirely different spectrum of outcomes than other transgender children.[18, para. 19]

Serano would like a rigorous test of the ROGD hypothesis. In the final section of the manuscript, Littman actually outlines future directions that her research might take. Specifically, she states that

…research is needed to explore: the multiple developmental pathways to gender dysphoria and transgender identification; the trajectories of gender dysphoria and transgender identification including desistance and persistence; the myriad of outcomes from social, medical, and surgical transition (including positive, negative, and mixed outcomes); and the role of exploratory psychotherapies that are neither gender identity-affirmative nor gender identity-reparative.[1, para. 18]

Littman’s ideas are speculative, but they are not mutually exclusive to the suggestions that trans activists and academics have for research that could confirm or falsify ROGD. Given Littman’s ideas for future research and the fact that she herself refers to her 2018 paper as “hypothesis generating rather than hypothesis testing,” one might assume that she would be eager to test her hypothesis through studies of the sort that Serano describes. However, Littman has moved directly on to publishing work on detransitioners as opposed to on trans adolescents themselves, which is flawed in its own right.[21, 22] Furthermore, her plans for future research presented at a recent Genspect conference do not appear to include any research similar to what Serano proposed.[12]

Conclusions

In conclusion, this response raises questions as to the impartiality of Littman’s future research, and demonstrates a defensive mindset of a “pet theory” that is troubling to see in someone who presents herself as an objective investigator. However, it also is a microcosm of the rhetoric that anti-trans campaigners (who Littman seems unwilling to condemn) use:

  1. Misrepresenting current medical practices to exaggerate the ease with which trans adolescents can access transition-related healthcare.
  2. Portraying trans activists’ defense of these practices as irrational and ideologically driven, irrespective of their actual arguments; furthermore, acting as if the medical establishment is on board with these activists’ positions even when it is not.
  3. Ignoring existing research in the field and insisting on future research to fill supposed knowledge gaps without actually proposing any such research, let alone conducting it.

As attacks on trans youths’ right to healthcare ramp up early into 2022, trans advocates must be more prepared than ever to identify and counter these tactics.

References

  1. Littman, L. (2020). The use of methodologies in Littman (2018) is consistent with the use of methodologies in other studies contributing to the field of gender dysphoria research: Response to Restar (2019). Archives of Sexual Behavior, 49(1), 67–77. Link
  2. Littman, L. (2018). Parent reports of adolescents and young adults perceived to show signs of a rapid onset of gender dysphoria. PLOS ONE, 13(8), e0202330. Link
  3. Restar, A. J. (2020). Methodological critique of Littman’s (2018) parental-respondents accounts of “rapid-onset gender dysphoria.” Archives of Sexual Behavior, 49(1), 61–66. Link
  4. World Professional Association for Transgender Health. (2012). Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People [7th Version]. Link
  5. TH Group Collective Analysis SOC8 Statement Feedback Worksheet. (2021). International Transgender Health Group. Link
  6. Hembree, W. C., Cohen-Kettenis, P. T., Gooren, L., Hannema, S. E., Meyer, W. J., Murad, M. H., Rosenthal, S. M., Safer, J. D., Tangpricha, V., & T’Sjoen, G. G. (2017). Endocrine Treatment of Gender-Dysphoric/Gender-Incongruent Persons: An Endocrine Society* Clinical Practice Guideline. The Journal of Clinical Endocrinology & Metabolism, 102(11), 3869–3903. Link
  7. Ashley, F. (2022). Youth should decide: The principle of subsidiarity in paediatric transgender healthcare. Journal of Medical Ethics, medethics-2021-107820. Link
  8. WPATH Position On “Rapid-Onset Gender Dysphoria (ROGD)”. (2018). World Professional Association for Transgender Health. Link
  9. Chong, L. S. H., Kerklaan, J., Clarke, S., Kohn, M., Baumgart, A., Guha, C., Tunnicliffe, D. J., Hanson, C. S., Craig, J. C., & Tong, A. (2021). Experiences and Perspectives of Transgender Youths in Accessing Health Care: A Systematic Review. JAMA Pediatrics, 175(11), 1159–1173. Link
  10. “ROGD – What is it?”. (2020, April 27). Our Duty. Link
  11. Home. (n.d.). Parents of ROGD Kids. Link
  12. Duval, D. (2021, November 22) First ever conference on ROGD packs clinical and emotional punch. Genspect. Link
  13. @genspect. (2021, August 16). [Tweet]. Link
  14. Twitter search for #RogdAwarenessDay. (n.d.). Twitter. Link
  15. Gingerich, M. (2022, February 4). Major TV news outlets are leaving it to Fox to cover the national assault on trans youth. Media Matters for America. Link
  16. Grant, M. G. (2022, February 10). Republicans are already trying to pass as many anti-trans bills as possible in 2022. The New Republic. Link
  17. Sagan standard. (2021). In Wikipedia. Link
  18. Serano, J. (2018, August 22, updated 2021). Everything you need to know about rapid onset gender dysphoria. Medium. Link
  19. Turban, J. (2022, January 24). The evidence for trans youth gender-affirming medical care. Psychology Today. Link
  20. Publications. (n.d.). Gender Dysphoria Affirmative Working Group. Link
  21. Littman, L. (2021). Individuals treated for gender dysphoria with medical and/or surgical transition who subsequently detransitioned: A survey of 100 detransitioners. Archives of Sexual Behavior, 50(8), 3353–3369. Link
  22. Leveille, L. (2021). Littman Tries to Prove ROGD by Surveying Detransitioners, Fails Spectacularly. Health Liberation Now! Link
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