Rapid Onset Gender Dysphoria and the U.S. Transgender Survey of 2015: A Response to Critics

Even by ROGD-skeptics’ own restrictive definitions, the U.S. Transgender Survey shows evidence of 2,127 people who reported a time course consistent with ROGD.

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Rapid onset gender dysphoria (ROGD) is one of the most controversial issues in the ongoing debate about transgender identity and medical sex trait modification in youth. In a new Letter to the Editor in the Archives of Sexual Behavior, we (and co-author Michael Biggs) criticize an article by Jack Turban et al., “Age of Realization and Disclosure of Gender Identity Among Transgender Adults,” which argues against ROGD.

We were heartened to see even vocal opponents of the ROGD hypothesis say that our Letter is “a reasonable critique of Turban’s methods.” Critics of ROGD who are scientific and open-minded should at least be able to recognize poor attempts to criticize the hypothesis. We also appreciate the criticisms our Letter has received since it came out, even if some of these criticisms were enveloped in ad hominem fallacies.

In this article, we respond to five points raised by critics.

Given that ROGD is a new and important area of research, and that the health and wellbeing of youth is on the line, we believe thoughtful scientific debate is essential.

1: The place of USTS-15 in the ROGD debate

We did not argue and do not think that the U.S. Transgender Survey of 2015 is the most valuable data source for evaluating the ROGD hypothesis. USTS-15 surveyed adults only, and at a time when adolescent-onset gender dysphoria was still on the rise. As such, it is not the ideal resource for exploring the ROGD hypothesis. We point this out in our Letter. What we did argue is: even if you agree with Turban et al. that the USTS-15 is a good resource for exploring ROGD, the USTS-15 data actually provides more evidence for than against it.

2: Evidence for ROGD in USTS-15

As we point out in the Letter, the USTS-15 asks three questions:

• 3.1 At about what age did you begin to feel that your gender was “different” from your assigned birth sex?

• 3.2 At about what age did you start to think you were trans (even if you did not know the word for it)?

• 3.3 At about what age did you first start to tell others that you were trans (even if you did not use that word)? [Or] I have not told others that I am trans.

Turban et al. measure time from “realization” of a transgender identity to disclosing that identity to others using Q3.1 as their proxy for “realization” of a transgender identity. Moreover, they do so only for adults who said they realized their trans identity before age 10. We questioned both of these choices (more on using Q3.1 later). Measuring time to disclosure among those who said they realized at age 11 or older (meaning, ROGD relevant experiences), we found that the mode was 1 year and the median 3 years.

A more intuitive proxy for “realization” would be Q3.2, “started to think you were trans.” When we use Q3.2 as the proxy, the results are extremely supportive of the ROGD hypothesis, as the tables below demonstrate:

The median time from realization to disclosure is one year or less. Approximately two thirds of respondents (n = 3,685) said that they went from “starting to think I am trans” to disclosing a trans identity to others within a time frame no reasonable person can deny is “rapid.”

However, in our Letter we wanted to be generous to Turban et al.’s ROGD-antagonistic approach, which is why our analysis in the Letter (Table 1) uses Q3.1 (Turban et al.’s choice) as the proxy for “realization.” Using that proxy, we found a mode of 1 year and a median of 3 years. Some critics claimed that 3 years is not “rapid” (we address this question below). For now, we thought it might be useful to provide the full data on time from realization to disclosure using Q3.1:

These data show that out of 5,880 age-relevant respondents, 1,310 went from “first feeling gender was different from sex” to disclosing their trans identity within 1 year, and 817 did it in less than a year. This makes for a total of 2,127, or approximate one-third of the group, who, by Turban et al.’s restrictive assumptions, developed and disclosed a trans identity to others in a very short time frame.

In sum, between 1/3 and 2/3 of respondents reported a timeline that supports the ROGD hypothesis. (Note: Littman never suggested that ROGD describes all adolescents and young adults who identity as transgender. She proposed it as a pathway to GD in a subset of this demographic.) Even critics of ROGD must admit that the USTS-15 shows some evidence of the phenomenon.

3: Is Q3.1 a reliable proxy?

Should we measure time to disclosure from when respondents first “started to feel their gender is different from their sex” (Q3.1) or from when they “first started to think they are trans even if they didn’t have words to express it at the time” (Q3.2)? Critics of ROGD choose the first option because it produces a longer (i.e., less “rapid”) trajectory of development. As we’ve seen, however, even with this approach, one-third of respondents in the relevant group still went from not having a problem with their sex to rejecting it in the space of one year or less.

One problem here is recall bias. As we point out in the Letter, USTS-15 recruited respondents through advocacy networks, and contemporary trans advocacy relies on unsubstantiated theories of innate, even biological, gender identity (due to the political potency of these theories and their relevance in American constitutional litigation). The combination of a psychological inclination (need?) to believe one was “born this way” and sampling bias means that we shouldn’t take respondents’ answers to Q3.1 at face value. Turban et al. do, however, and we think that leaves their study with a high risk of bias.

Let us demonstrate this bias with a common scenario. Imagine an autistic girl who, at age 10, starts to realize she doesn’t fit in socially. Two years later, at age 12, she is introduced to gender identity theory and starts consuming YouTube content by transgender influencers. She begins to use transgender identity as a lens through which to interpret her life experiences and specifically her social maladjustment. Ah ha! she thinks. This is why I’ve been feeling that I don’t fit in! At age 13, she tells her parents that she is trans. Five years later, she participates in USTS-15 and recalls feeling her “gender was different from her sex” at age 10.

This girl, who fits the ROGD profile perfectly, is retrospectively interpreting her experiences from age 10 to 12 to meet her current psychological needs. She didn’t spend ages 10 to 12 thinking about her “gender.” Instead, she convinced herself in hindsight that that was the problem all along. 

Recall bias means that USTS-15 has no way of telling apart respondents like our hypothetical autistic girl and respondents who really did start thinking about “their gender being different from their sex” three years before disclosing a trans identity to others. Neither Turban et al. nor we can do more than speculate about what went on in the minds of respondents during the 2 years between the time points captured in Q3.1 and Q3.2. In fact, we can’t even know that they did start “feeling different” (whatever that means) at a median of 3 years before disclosure.

Unlike Turban et al., we acknowledge this uncertainty in USTS-15. We argue that Q3.2 is the more the natural choice for measuring identity development because it contains less ambiguity (it asks about first realization of trans identity explicitly). By contrast, Turban et al. assume, without any evidence and while ignoring the problems of recall and sampling bias, that if a respondent said “I start feeling my gender was different” at age 10, then there is no question the respondent first “realized” a “transgender or gender diverse” identity at age 10.

4: What counts as “rapid”?

Here we get to what appears to be the main criticism of our Letter, which is that 3 years—the median time from realization to disclosure using Q3.1—is not “rapid” at all. Others said we were moving the goal posts for what counts as rapid in order to keep the ROGD theory alive.

What “rapid” means is a good question. We do not address it in our Letter, and to our knowledge it has never really been discussed in the academic literature. Before we offer some thoughts, we wanted to emphasize, again, that even if we use Turban’s method but restrict it to the relevant age group (18-24), the USTS-15 shows evidence of 2,127 respondents who have onset of gender dysphoria or trans identity within one year or less.

Critics of ROGD will naturally want to define “rapid” as narrowly as possible so as to minimize the incidence of ROGD. Thus, for instance, Assigned Media’s Evan Urquhart writes: “In 2018, Lisa Littman estimated that youth with ROGD declared their trans identity between one week and three months after displaying signs of gender dysphoria. When the data failed to back this up, she and other proponents did away with the rapidity.”

Actually, only 26 percent of Littman’s 2018 sample went from non-dysphoric to dysphoric in three months or less. The times from non-dysphoria to dysphoria in the remainder of the sample were:

• 4-6 months: 12.4%

• 7-9 months: 4%

• 10-12 months: 11.6%

• More than 12 months: 8%

• Don’t know: 5.6%

• Did not seem at all gender dysphoric when they announced a trans identity: 32.4%

Littman did not define what counts as “rapid.” She merely presented the findings from her survey. What Urquhart is doing here is setting up a straw man. By misrepresenting Littman’s findings, and then mischaracterizing those findings as a definition, Urquhart is leading readers to believe that Littman (along with Sapir and Biggs) are now redefining “rapid” due to inconvenient findings in USTS-15. Littman no doubt considers three months or less to be “rapid,” but it hardly follows that her original hypothesis considers anything beyond three months to be non-rapid.

Let us, once again, try to be as charitable as we can to critics of ROGD. Let’s suppose that Q3.1 is the correct proxy for “realization.” Let’s assume that the median is 3 years from realization to disclosure. And let’s forget, for a moment, that even under these assumptions, 2,127 respondents still said that they went from no issues with their sex to trans-identified within a year or less.

Is 3 years “rapid”? Rapid is a relative term. Turban et al. report that the median time from realization to disclosure (in the “early realization”) cohort is 14 years. Three years is rapid compared to 14.

More importantly, until recently the two recognized subtypes of gender dysphoria were adult-onset (almost all middle-aged males) and childhood-onset. The latter was observed to manifest from very early in life through gender nonconformity and confusion. The Dutch protocol, which started the pediatric transition experiment, recommended only adolescents who had childhood-onset of symptoms. By the time they emerged into puberty and were eligible for puberty blockers, candidates would have had to be dysphoric for quite a few years.

Thus, a possible definition of “rapid” is: dysphoria that arises in the context of puberty as opposed dysphoria that begins much earlier in life and persists into adolescence. The first sentence of Littman’s 2018 article abstract reads: “In on-line forums, parents have reported that their children seemed to experience a sudden or rapid onset of gender dysphoria, appearing for the first time during puberty or even after its completion” (our emphasis).

Littman might have spared us the headache of quibbling over the exact meaning of “rapid” by choosing another term—say, “adolescent-onset gender dysphoria with novel and unknown etiology.” As we’ll discuss in a moment, the hypothesis about rapidity, though important, is not more important than the hypothesis about trans identity being a maladaptive coping mechanism or arising due to social/peer influence or internalized homophobia. If trans identity is secondary to these other issues, that has massive implications for clinical care. The precise speed at which a teenager comes to use a trans identity as a way to cope with, say, internalized homophobia and a history of sexual trauma, is less important than recognizing the trans identity as a coping mechanism and not letting it get in the way of a more productive therapeutic approach.

Some critics might argue that 3 years cannot be rapid, period. But this claim depends on context. Is a 1-month period from spraining one’s ankle to full recovery rapid? That depends on whether we’re talking about an 80-year-old with multiple health problems or a 15-year-old athlete.

There is a tendency among gender clinicians and researchers to treat “gender” as an exceptional aspect of human identity. Thus, when considering what counts as “rapid,” it’s worth thinking about the pace at which other aspects of human identity develop—for instance, patriotic attachment, religious identity, relationships with family members, realizing our vocation in life, and so on. These aspects typically take far longer than 3 years. Sometimes they never end.

Take the example of finding your vocation. It’s common these days for people to finally figure out what they want to do in life in their mid- or late-thirties, after more than a decade of trying things out, experiencing disappointment, going through periods of feeling everything is pointless and nothing is fulfilling, and so on. Some people go through life never figuring out what their calling is. Now, imagine we were to come across a teenager who, in the space of 3 years between age 12 and 15, figured out, definitively, that her calling in life is to be a biochemical engineer. Could we not reasonably say that this teenager had a rapid-onset of vocational identity?

Going from not even thinking about one’s sex as a problem to “feeling uncomfortable being a girl” to “knowing I’m a boy who was assigned the wrong sex at birth” is, to put it mildly, a dramatic change. To go through such a change in the space of even 3 years can reasonably be described as “rapid.”

5: Can children identify as transgender in secret?

According to Turban et al.’s interpretation of USTS-15 data:

The median age at which those in the childhood realization group first told someone about their gender identity was 20 years and the median number of years between realizing their TGD identities and telling another person was 14 years. With survey weights applied, the childhood realization group had a median of 17 years between realizing their identities and first telling someone, with a median of age 22 for the latter.

Thus, individuals who “realized” a transgender identity in childhood did so at a very early age and somehow managed to conceal it from their caregivers for many years.

In our Letter, we question Turban et al.’s assumption that young children can hide their confusion about or discomfort with their sex from their parents. Four-year-olds are not particularly good at hiding information about their favorite color, let alone about “being transgender.” Turban and his coauthors might have avoided this credibility-destroying claim by taking USTS-15 respondents’ recollections about identity development with a grain of salt (which they do, readily and happily, when it comes to the experiences of detransitioners).

One critic of our paper took to X to point out that, in fact, “parents being unaware of their children's gender incongruence/dysphoria is pretty commonplace.” The critic linked to a 2021 study from the Toronto gender clinic, which she says shows that “about half of caregivers didn’t realize their children were trans until they came out, despite the children realizing that on average years before.”

It’s misleading, however, to say that the study corroborates Turban et al.’s conclusions. The finding in the 2021 study pertains to young adolescents who recalled having first “recognition of gender incongruence” at median age 11.3. Adolescents are definitely more capable than children of withholding information from their parents. Does that mean parents won’t detect that something is going on with their kid? Of course not. But the inner lives of 12- or even 10-year-olds are typically harder for parents to understand than the inner lives of 4-year-olds.

Importantly, the authors of the 2021 study noted a crucial limitation: “As a retrospective study, it is subject to recall bias.” In other words, there’s no way to know whether, say, a respondent who recalled first realizing her gender incongruence at age 9 really had that experience. Even so, the study found that among those who became “gender incongruent” in adolescence, time from development of this incongruence to its disclosure to caregivers was a median of two years.

As Littman explicitly stated in her 2018 article, “The argument to surface from this study is not that the insider perspectives of [adolescents and young adults] presenting with signs of a rapid onset of gender dysphoria should be set aside by clinicians, but that the insights of parents are a pre-requisite for robust triangulation of evidence and fully informed diagnosis.” We emphasize a similar point in our Letter when we say that “both ‘internal processes’ (which are more subjective) and parental reports (which are more objective) are relevant to the question of identity development and disclosure.” We reject the assumption of Turban et al. that the only thing that counts is “internal identity processes.”

Children are not islands. They are not dark and mysterious secrets to those who care for them on a daily basis.

Conclusion

We are thankful to all those who offered criticisms of our Letter, even if some of criticisms could have been more substantive and expressed in good faith. We emerged from this process more convinced than before that ROGD needs more research, and that there is evidence in support of ROGD that even the most ardent of anti-ROGD critics must concede. In the end, we owe it to children and their families to have rational, evidence-based debate on why so many kids are identifying as transgender and seeking various forms of body modification.

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