Some of you may have seen an article by Samuel Veissière Ph.D. in Psychology Today last week. Below is a response on behalf of the Gender Dysphoria Affirmative Working Group.
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December 5, 2018
An open letter to the owners, editors, members, advertisers, and others at Psychology Today:
We are a broad, international coalition of prominent medical and mental health professionals, academics, researchers, activists, and allies, some who are transgender-identified and others cisgender allies, all with vast expertise in gender and sexuality and troubled by the notion of “Rapid Onset Gender Dysphoria.” Together we have published hundreds of peer-reviewed journal articles, written dozens of books, given countless lectures at universities, professional organizations, in the media, and elsewhere, and have counseled thousands of transgender and gender nonbinary youth. We established the Gender Dysphoria Affirmative Working Group to highlight the overwhelming data demonstrating that evidence-based affirmative approaches yield happier and better adjusted children and that disaffirming approaches produce significant harm. Our website can be found here: www.gdaworkinggroup.com
We wish to refute in the strongest possible terms the article by Samuel Veissière Ph.D. and the study he cited by Dr. Lisa Littman.
The Littman (2018) study has been widely contested as methodologically flawed and unethical, proceeding from an overt ideological bias. The notion of “Rapid Onset Gender Dysphoria” is based solely on that one publication and runs counter to the evidence-based affirmative standard of care - in which the youth’s self-reported gender is respected and where the youth is provided the safety and freedom to explore the gender and identity without judgment or predetermined outcome.
The World professional Association for Transgender Health(WPATH) and the American Academy of Pediatrics(AAP) both address the need to provide empathetic, nurturing environments, and reject attempts, “to instill fear about the possibility that an adolescent may or may not be transgender with the a priori goal of limiting consideration of all appropriate treatment options.” Furthermore, the AAP, “supports policies that are gender-affirming for children – an approach that is supported by other key professional organizations.”
The Pediatric Endocrine Society arrives at the same conclusion, stating, "…the purpose of this Position Statement is to emphasize the importance of an affirmative approach to the health care of transgender individuals..."and that “transgender youth have optimal outcomes when affirmed in their gender identity, through support by their families and their environment, as well as appropriate mental health and medical care. For this reason, the Pediatric Endocrine Society Special Interest Group on Transgender Health joins other academic societies involved in the care of children and adolescents in supporting policies that promote a safe and accepting environment for gender-nonconforming/transgender youth, as well as adequate mental health and medical care." (Lopez et al., 2016)
A more comprehensive list of the dozens of organizations with public statements supporting the healthcare needs of transgender youth and adults can be found here: https://www.lambdalegal.org/sites/default/files/publications/downloads/resource_trans-professional-statements_09-18-2018.pdf
The positions of these organizations, along with our own, are based on the best available research. Affirmative approaches demonstrate far-reaching improvements in quality of life, relationship satisfaction, self-esteem and self-confidence, and clearly show reductions in depression. anxiety, substance use, school dropout, incarceration, homelessness, self-harm, and suicide (Pyne 2016; Riley et al 2011; Russel et al 2018; Snapp et al 2015; Travers et al 2012). Given space and time, these youth discover what gender is authentic and what level of transition is appropriate for them, if any.
A 2018 Cornell University metastudy concluded that “[93% of peer reviewed studies] found that gender transition improves the overall well-being of transgender people… None of the reviewed studies showed that gender transition harms well-being.” Others have documented that rates of regret are miniscule (Olson et al, 2018; Wiepjes et al, 2018).
Conversely, critiques of Littman’s article have cited numerous issues (Ashley, 2018; Ashley & Baril, 2018; Barasch, 2018; Borg, 2018; Serano, 2018; Tannehill, 2018):
· The sample group of parents was drawn exclusively from websites openly hostile to transgender youth and their issues, thus deliberately skewing the results.
· Littman failed to acknowledge or account for the skew she introduced.
· Survey questions seem directed toward predetermined conclusions. The study essentially surveyed the people who invented or were predetermined to support ROGD on whether they believe ROGD is real, then made its conclusions based on these beliefs.
· She spoke with no trans youth, despite drawing conclusions on how such youth arrived at their trans identities, instead basing her conclusions solely on parents’ suppositions and skeptical beliefs.
· The ‘rapid onset’ often reported by parents is not a new phenomenon. Youth very commonly will delay coming out in hostile environments, being afraid to disclose due to minority stress factors including social stigma, internal stress, fears of rejection by family and friends, and legitimate concerns about violence. Given that these parents sought out hostile websites, the fears of these youth would seem to have been justified.
· The disaffirming approaches suggested by the Littman study and also by Veissière’s post are likely to yield worsening mental health outcomes and a deterioration of the parent-child relationship.
· Littman herself has no personal experience working with transgender youth.
There are many reports that when Littman presented her preliminary results, she was given extensive critique on the poor scientific quality of her research. She made no attempts to address these issues in her final paper, again suggesting she placed ideology over scientific rigor. Some members of Gender Dysphoria Affirmative Working Group personally attended those sessions, and we have spoken to others with the same experience.
Studies also demonstrate that disaffirming approaches, such as those advocated by the proponents of “Rapid Onset”, cause harm. There are a great deal of peer reviewed papers documenting that the high rates of depression, anxiety, substance abuse, poor school performance often identified in this population manifest primarily in youth from unsupportive environments (Bariola et al 2015; Bokting et al 2105; Hidalgo et al 2013; Roberts et al 2012).
Klein and Golub (2016) report that a staggering 41% of transgender people have attempted suicide, and that 26.3% report misusing drugs or alcohol to cope with stigma related to their transgender identity. The negative consequences of substance misuse and suicidal ideation and gestures “increased significantly with increasing levels of family rejection.”
Simultaneously, youth from environments where they are provided the freedom and validation to explore and determine their gender for themselves show no higher rates of these issues than their cisgender (non-trans) peers (Durwood, et al 2017; Olson, et al 2016).
More of these studies are excerpted below.
We also refute the charge that those opposing the Littman study are ‘radical transgender activists attempting to silence research we dislike’. We oppose any attempt to manipulate research in a way that would cause harm to our patients, community members, and children. The Littman study has been widely criticized as being methodologically flawed, ideologically biased, and as such is bigotry masquerading as science. Poor science remains poor science.
Psychology Today represents a trusted source for information and referrals on mental health. Publishing an article based on poor, biased research that encourages practices found to be harmful is both irresponsible and a disservice to your readers and their clients.
We urge you to publish our letter and also to reconsider and withdraw the publication of such a flawed article.
The Gender Dysphoria Affirmative Working Group
Noah Adams, MSW
Elsa Almås, PhD
Erica E. Anderson, Ph.D.
Esben Esther Pirelli Benestad, MD
Ady Ben-Israel, PhD
Peter Chirinos, MA
Damon Constantinides, PhD, LCSW
Diane Ehrensaft, Ph.D.
Tony Ferraiolo, CPC
Dr. Robert Garofalo
Shawn V. Giammattei, Ph.D.
Melanie A. Gold, DO, DMQ, FAAP, FACOP
Linda A Hawkins, PhD, MSEd, LPC
Marco A. Hidalgo, PhD
Laura A. Jacobs, LCSW-R
Aron Janssen, MD
Randi Kaufman, PsyD
Colt Keo-Meier, PhD
S.J. Langer, LSCW-R
Sean Lare, LCSW-C
Arlene Istar Lev LCSW-R, CASAC, CST
M. Dru Levasseur, Esq.
Jean Malpas, LMHC, LMFT
Zack Marshall, MSW PhD
Denise Medico, Ph.D
Christine Milrod, Ph.D
Margaret Nichols, Ph.D.
Johanna Olson-Kennedy, MD
Simon Pickstone-Taylor, MBChB
Marjorie Rabiau, Ph.D.
Stephen M. Rosenthal, MD
Cianán Russell, Ph.D.
Hershel Russell M.Ed
Dr. Annie Pullen Sansfaçon, PhD
Herb Schreier M.D.
Julia Serano, Ph.D.
Caroline Shahbaz, BBSc(Hons), MPsych
John B. Steever, MD
Françoise Susset, Psy.D.
Brynn Tannehill, M.S.
Barbara E. Warren Psy.D., LMHC
Erika P. Volkmar, DDS
Linda Wesp, MSN, FNP-C, AAHIVS
1. The Gender Affirmative Model: What We Know and What We Aim to Learn
Published in: Human Development. October, 2013. Authors: Marco A. Hidalgo, Diane Ehrensaft, Amy C. Tishelman, Leslie F. Clark, Robert Garofalo, Stephen M. Rosenthal, Norman P. Spack, Johanna Olson
"Children not allowed these freedoms by agents within their developmental systems (e.g., family, peers, school) are at later risk for developing a downward cascade of psychosocial adversities including depressive symptoms, low life satisfaction, self-harm, isolation, homelessness, incarceration, posttraumatic stress, and suicide ideation and attempts…”
2. Family Rejection as a Predictor of Suicide Attempts and Substance Misuse Among Transgender and Gender Nonconforming Adults
Published in: LGBT Health. May 25, 2016. Authors: Augustus Klein & Sarit A. Golub
"42.3% of [transgender adults] reported a suicide attempt and 26.3% reported misusing drugs or alcohol to cope with transgender-related discrimination… family rejection was associated with increased odds of both behaviors. Odds increased significantly with increasing levels of family rejection."
3. Statement on Gender Affirmative Approach to Care from the Pediatric Endocrine Society Special Interest Group on Transgender Health
Published by: Pediatric Endocrine Society Transgender Health Special Interest Group. October 20, 2016. Authors: Lopz, X, Marinkovic, M, Eimicke, T, Rosenthal, SM, Olshan, JS.
"The purpose of this Position Statement is to emphasize the importance of an affirmative approach to the health care of transgender individuals, as well as to improve the understanding of the rights of transgender youth..."
"In conclusion, transgender youth have optimal outcomes when affirmed in their gender identity, through support by their families and their environment, as well as appropriate mental health and medical care. For this reason, the Pediatric Endocrine Society Special Interest Group on Transgender Health joins other academic societies involved in the care of children and adolescents in supporting policies that promote a safe and accepting environment for gender-nonconforming/transgender youth, as well as adequate mental health and medical care."
4. Ensuring Comprehensive Care and Support for Transgender and Gender-Diverse Children and Adolescents
Published By: The American Academy of Pediatrics. September, 2018. Committee on Psychosocial Aspects of Child and Family Health, Committee on Adolescence, Section on Lesbian, Gay, Bisexual, and Transgender Health and Wellness
“Supportive involvement of parents and family is associated with better mental and physical health outcomes. Gender affirmation among adolescents with gender dysphoria often reduces the emphasis on gender in their lives, allowing them to attend to other developmental tasks, such as academic success, relationship building, and future-oriented planning.
5. Gender nonconforming youth: current perspectives
Published in: Adolescent Health, Medicine and Therapeutics. 2017. Author: Diane Ehrensaft.
"The gender affirmative model is defined as a method of therapeutic care that includes allowing children to speak for themselves about their self-experienced gender identity and expressions and providing support for them to evolve into their authentic gender selves, no matter at what age.”
6. Mental Health of Transgender Children Who Are Supported in Their Identities
Published in: Pediatrics, February, 2016. Authors: Kristina R. Olson, Lily Durwood, Madeleine DeMeules, Katie A. McLaughlin.
"Socially transitioned transgender children who are supported in their gender identity have developmentally normative levels of depression and only minimal elevations in anxiety, suggesting that psychopathology is not inevitable within this group… socially transitioned transgender children have notably lower rates of internalizing psychopathology than previously reported among children with GID living as their natal sex."
7. Demographic and Psychosocial Factors Associated With Psychological Distress and Resilience Among Transgender Individuals
Published in: The American Journal of Public Health. October, 2015. Authors: Emily Bariola, BA, Anthony Lyons, PhD, William Leonard, BSc, BA, Marian Pitts, PhD, Paul Badcock, PhD, and Murray Couch, BA.
“The findings indicated that, relative to other sources, family of origin may have the most influence in protecting against psychological distress… our findings support a need to encourage family members to be open and receptive sources of support.”
“…frequent contact with LGBT peers was revealed as a significant [protective] factor… for transgender individuals, frequent peer contact may be particularly important for developing individual resilience, as gender transitioning can be a complex and challenging process and having peers who share similar experiences may provide not only a sense of support and understanding, but also a sense of belonging.”
8. Social Support Networks for LGBT Young Adults: Low Cost Strategies for Positive Adjustment
Published in: Family Relations. July, 2015. Authors: Shannon D. Snapp, Ryan J. Watson, Stephen T. Russell, Rafael M. Diaz, Caitlin Ryan.
“Our study adds to the growing body of evidence that family support, both general and sexuality specific, is a crucial factor in LGBT youth’s health and well-being…”
“Two variables were most relevant in predicting adjustment: (a) the percentage of friends who knew about participants’ sexual or gender identity and (b) support related to being LGBT from friends. The presence of a network of friends to whom youth can be out has been linked to measures of health and well-being…”
“Although friendship support is clearly associated with positive well-being in young adulthood, it appears that family acceptance has a stronger overall influence when other forms of support are considered jointly.”
9. Stigma, Mental Health, and Resilience in an Online Sample of the US Transgender Population
Published in: American Journal of Public Health. May, 2013. Authors: Walter O. Bockting, PhD, Michael H. Miner, PhD, Rebecca E. Swinburne Romine, PhD, Autumn Hamilton, HSD, and Eli Coleman, PhD.
“… family support, peer support, and identity pride all were negatively associated with psychological distress, confirming that these assets are protective factors. Moreover, peer support significantly moderated the relationship between enacted stigma and psychological distress, thus emerging as a demonstrated factor of resilience in the face of actual experiences of discrimination. Only at high (but not low or medium) levels of peer support was enacted stigma not associated with psychological distress, which suggests that the negative impact of enacted stigma on mental health is pervasive and that regular contact with peers is necessary to ameliorate it.”
“Together, these results offer support for the value of transgender individuals connecting with similar others, possibly providing the opportunity to question stigma from the majority culture and reappraise their experiences in a self-affirmative way, which is consistent with what has been postulated and observed among gay and lesbian individuals. This finding is particularly pertinent because previous research found that transgender people have higher levels of depression and lower levels of peer and family support than their gay, lesbian, and bisexual counterparts. These results support a need to promote resilience by facilitating ample peer support.”
10. The Needs of Gender-Variant Children and Their Parents: A Parent Survey
Published in: International Journal of Sexual Health. 2011. Authors: Elizabeth Anne Riley, Gomathi Sitharthan, Lindy Clemson, Milton Diamond.
“The results of this study support the development of affirmative approaches in supporting gender-variant children and their parents. This is particularly evidenced by the parents’ own approaches to supporting their children where parents experimented with different ways of responding to various scenarios and realized that acceptance of their child was the only option as they learned that their child’s need for expression was not changed by their attitude or management of the behavior.”
Ashley, F. (2018). Rapid-Onset Gender Dysphoria: A Parental Epidemic? Impact Ethics.com.
Ashley, F. & Baril, A. (2018). Why ‘Rapid-Onset Gender Dysphoria’ is bad science. Medium.com.
Barasch, A. (2018). Criticism Is Not Censorship: A poorly designed study of “rapid onset gender dysphoria” deserves serious scrutiny, not protection from “activist interference.” Slate.com.
Bariola, BA., et al. (2015). Demographic and Psychosocial Factors Associated With Psychological Distress and Resilience Among Transgender Individuals. The American Journal of Public Health.
Bokting, W., Miner, MH., Swinburne Romine, RE., Hamilton, A., Coleman, E. (2013). Stigma, Mental Health, and Resilience in an Online Sample of the US Transgender Population. American Journal of Public Health.
Borg, L. (2018). Transgender Article Removed at Brown Brings Controversy. Providence Journal.
Cornell Chronicle. (2018). Analysis Finds Strong Consensus on Effectiveness of Gender Transition Treatment.
Durwood, L., McLaughlin, KA, Olson, KR. (2017). Mental Health and Self-Worth in Socially Transitioned Transgender Youth Journal of the American Academy of Child and Adolescent Psychiatry.
Hidalgo, MA., Ehrensaft, D., Tishelman, AC, Clark, LF, Garofalo, R., Rosenthal, SR., Spack, NP, Olson,J. (2013). The Gender Affirmative Model: What We Know and What We Aim to Learn. Human Development.
Klein, A, & Golub, SA. (2016). Family Rejection as a Predictor of Suicide Attempts and Substance Misuse Among Transgender and Gender Nonconforming Adults. LGBT Health.
Littman, L. (2018). Rapid-Onset Gender Dysphoria in Adolescents and Young Adults: A Study of Parental Reports. PLOS One.
Lopez, X., et al. (2016). Statement on Gender Affirmative Approach to Care from the Pediatric Endocrine Society Special Interest Group on Transgender Health. Pediatric Endocrine Society Transgender Health Special Interest Group.
Olson-Kennedy, J., Warus, J., Okonta, V. (2018). Chest Reconstruction and Chest Dysphoria in Transmasculine Minors and Young Adults - Comparisons of Nonsurgical and Postsurgical Cohorts. Journal of the American Medical Association.
Olson, KR, Durwood, L, DeMeules, M, McLaughlin, KA. (2016). Mental Health of Transgender Children Who Are Supported in Their Identities. Pediatrics.
Pyne, J. (2016). “Parenting Is Not a Job ... It’s a Relationship”: Recognition and Relational Knowledge Among Parents of Gender Non-conforming Children. Journal of Progressive Human Services.
Riley , E.A., Sitharthan, G, Clemson, L, & Diamond, M. (2011). The Needs of Gender-Variant Children and Their Parents: A Parent Survey. International Journal of Sexual Health.
Roberts, AL., Rosario, M., Corliss, HL., Coenen, KC., Austin, SB. (2012).
Childhood Gender Nonconformity: A Risk Indicator for Childhood Abuse and Posttraumatic Stress in Youth. Pediatrics.
Russell, TR., Pollitt, AM., Li, G., Grossman, AH. (2018). Chosen Name Use Is Linked to Reduced Depressive Symptoms, Suicidal Ideation, and Suicidal Behavior Among Transgender Youth. Family Relations.
Serano, J. (2018). Everything You Need to Know About Rapid Onset Gender Dysphoria. Medium.com.
Snapp, SD., Watson, RJ., Russell, ST., Diaz, RM., & Ryan, C. (2015). Social Support Networks for LGBT Young Adults: Low Cost Strategies for Positive Adjustment. Family Relations.
Stein, F. (2017). AAP Statement in Support of Transgender Children, Adolescents, and Young Adults. The American Academy of Pediatrics.
Tannehill, B. (2018). 'Rapid Onset Gender Dysphoria' Is Biased Junk Science. Advocate.com.
Travers, R, Bauer, G., Pyne, J., Bradley, K., Gale, L., Papadimitriou, M. (2012). Impacts of Strong Parental Support for Trans Youth. Trans Pulse Project.
Wiepjes CM, et al. (2018). The Amsterdam Cohort of Gender Dysphoria Study (1972-2015): Trends in Prevalence, Treatment, and Regrets. The Journal of Sexual Medicine.
World Professional Association for Transgender Health. (2018). WPATH Position on Rapid-Onset Gender Dysphoria. Retrieved from: https://www.wpath.org/media/cms/Documents/Public%20Policies/2018/9_Sept/WPATH%20Position%20on%20Rapid-Onset%20Gender%20Dysphoria_9-4-2018.pdf