Canadian Clinic Data Find No Support for 'Rapid-Onset' Dysphoria, But Critics Say It Measured the Wrong Thing

Do Clinical Data from Transgender Adolescents Support the Phenomenon of "Rapid Onset Gender Dysphoria"?

Cohort & registry studies Mental health & suicide Rising diagnoses & social influence

Authors: Greta R. Bauer, Margaret L. Lawson, Daniel L. Metzger, Trans Youth CAN! Research Team
Journal: The Journal of Pediatrics
Year: 2022
Source: https://doi.org/10.1016/j.jpeds.2021.11.020

Summary

Researchers used first-visit surveys and clinic records from 173 teenagers under 16 referred to 10 Canadian gender clinics. They tested predictions of the 'rapid-onset gender dysphoria' idea, which suggests some teens develop a trans identity suddenly, often under peer influence. They compared teens who said they had realised their gender was different within about the past year with those who had known longer. The recent group did not have more mental health or developmental diagnoses or self-harm, and did not rely more on online or trans friends. They had less anxiety. The authors concluded the data did not support the idea. Critics, including Littman, replied that time since realising is not the same as onset at or after puberty, so the study may not have tested the idea at all. The small recent group, the under-16 limit and the clinic-only sample further limit what it can show.

Key findings

The study looked at 173 teenagers under 16 at a first visit for puberty blockers or hormones at 10 Canadian gender clinics in 2017–2019.
'Recent' meant a teen's current age was within 1 year of the age they said they realised their gender was different. Because ages were in whole years, this could cover up to almost 2 years.
After allowing for age and birth sex, recent realisers were no more likely to have depression, distress, recorded diagnoses, gender distress, self-harm or suicide attempts, or to rely on online, trans or parental support.
Recent realisers had less anxiety and were much less likely to have used marijuana in the past year (about one-tenth as likely), the opposite of what the idea predicts.
The whole group had high needs: 51.6% had a recorded mental health diagnosis, 25.9% a developmental diagnosis such as autism or ADHD, and 67.9% reported self-harm in the past year.
Results were much the same with a looser 2-year definition, except that the marijuana finding could then be chance.
Published letters from Lisa Littman and Joanne Sinai argued the study did not measure rapid-onset dysphoria, because it never looked at when dysphoria began relative to puberty.

Abstract

Although emergence of gender dysphoria at puberty is long established, a distinct pathway of rapid onset gender dysphoria was recently hypothesized based on parental data. Using adolescent clinical data, we tested a series of associations that would be consistent with this pathway, however, our results did not support the rapid onset gender dysphoria hypothesis.

Conclusion

We did not find support within a clinical population for a new etiologic phenomenon of rapid onset gender dysphoria during adolescence. Among adolescents under age 16 years seen in specialized gender clinics, associations between more recent gender knowledge and factors hypothesized to be involved in rapid onset gender dysphoria were either not statistically significant, or were in the opposite direction to what would be hypothesized. This putative phenomenon was posited based on survey data from a convenience sample of parents recruited from websites, and may represent the perceptions or experiences of those parents, rather than of adolescents, particularly those who may enter into clinical care. Similar analyses should be replicated using additional clinical and community data sources.

Methodological limitations

Measured the wrong thing: 'Recently realising' one's gender differs is not the same as dysphoria starting during or after puberty with no childhood signs, which is what the rapid-onset idea describes. Littman (2022) argued many teens in both groups could fit the idea, which undercuts the test.
One rough question: Recency came from a single question asking teens to look back, and subtracting whole-year ages means 'recent' could mean anything from under 1 to almost 2 years.
Too few recent teens to be sure: Sinai (2022) noted only about 24 teens (14%) were classed as recent. The results are so imprecise that 'no clear link' cannot be read as 'no link'.
Only compared clinic patients with each other: Everyone had already reached a specialist clinic, so the study compares groups of referred teens. It cannot test whether a distinct, socially influenced pattern exists in the wider population.
Older teens left out: Only under-16s were included, while the teens in Littman's parent reports averaged 16.4 years and included young adults. So older teens whose dysphoria began in adolescence were excluded by design.
Answers given while seeking treatment: Teens were surveyed at a first visit for blockers or hormones, when they may stress a long-standing identity. Sinai argued lower anxiety could reflect expecting treatment or recent acceptance, not long-standing dysphoria.
Peer influence poorly measured: Social influence was measured only by whether teens had supportive online or trans friends, not by friendship groups coming out together, timing of heavy social media use, or exposure to transition content.
Only a starting snapshot: The study cannot show what happened later, such as dysphoria fading, detransition or regret, which are the main concerns the rapid-onset idea raises.
Many tests: 13 results were tested without adjusting for the number of tests, so the two findings in the 'wrong' direction could themselves be chance.
Researchers also provide the treatment: The research team are researchers and clinicians from clinics that give puberty blockers and hormones to teens, and the paper presents these treatments as backed by professional bodies.

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Summary

Key findings

Abstract

Conclusion