Comment on “Outbreak: On Transgender Teens and Psychic Epidemics”

I wish to call attention to a recent article published in your journal (2017, Vol. 60, No. 3, pp. 345–366) in which the author, Lisa Marchiano, discusses a purported social contagion called “rapid-onset gender dysphoria” (2017b). This article misrepresents current research, including its own cited references, to cast this phenomenon as a threat and provides harmful advice for transgender youth and their parents.

The medical literature on so-called “rapid-onset gender dysphoria” consists of a single poster abstract (Littman, 2017) based on an online survey of parents. Littman claims that “this type of presentation is atypical and has not been studied to date” (4thWaveNow, 2016), but the DSM-5 discussion of gender dysphoria in adolescence already notes that “parents often report surprise because they did not see signs of gender dysphoria during childhood” (American Psychiatric Association, 2013, p. 455). And although Littman fails to name the websites on which she posted recruitment information for her survey, a Google search reveals that all three are explicitly dedicated to opposing gender transition for children and adolescents (4thWaveNow, 2016; Jones, 2017; Transgender Trend, 2016; Youth Trans-Critical Professionals, 2016). It is hardly surprising to find worsening parent–child relationships (Littman, 2017) or genuinely surprised parents in such a population. Indeed, adolescents who anticipate their parents’ negative reaction would be strongly motivated to avoid showing any signs of being transgender until their dysphoria becomes intolerable.

Marchiano cites two “pediatric transition doctors in the Netherlands who first pioneered the use of puberty blockers in dysphoric children [and who] caution against social transition before puberty” (2017b, p. 351)—which is accurate in that the cited work does “recommend that young children not yet make a complete social transition . . . before the very early stages of puberty” (de Vries & Cohen-Kettenis, 2012, p. 307). However, she fails to mention the same article’s statement that “right at the onset of puberty it becomes clear whether the gender dysphoria will desist or persist” (p. 311) or its recommendation to start puberty suppression (and optionally, social transition) early in puberty for transgender adolescents. This omission misrepresents the cited article as supporting Marchiano’s argument and contradicts its conclusion that “withholding intervention is even more harmful for the adolescents’ wellbeing” (p. 315) than the potential risks of early intervention. In fact, the same authors later report marked improvement in gender dysphoria, psychological functioning, and overall well-being in early adulthood after starting puberty suppression in adolescence (de Vries et al., 2014).

The consensus standard of care prescribes gender-affirming care for adolescents and a safe and supportive environment for younger children to explore their developing identities (American Psychological Association, 2015; Coleman et al., 2012; Deutsch, 2016; Hembree et al., 2017; Levine & American Academy of Pediatrics Committee on Adolescence, 2013; Sokkary, Gomez-Lobo, & American College of Obstetricians and Gynecologists’ Committee on Adolescent Health Care, 2017). Marchiano’s concern that “although this practice [of affirming transgender youths’ identities] will likely help small numbers of children, there may also be many false positives” (2017b, p. 345) inverts the facts on the ground: 1 in 189 adults in the United States is transgender (Crissman, Berger, Graham, & Dalton, 2017); transgender youth and adults face limited access to any form of transition-related health care (Gonzales & Henning-Smith, 2017; Shires, Stroumsa, Jaffee, & Woodford, 2017; Vance, Halpern-Felsher, & Rosenthal, 2015); and 18 percent of those who sought care found that professionals instead “tried to stop them from being transgender” (James et al., 2016, p. 109).

Dismissing the effectiveness of this care, Marchiano (2017b, p. 351) cites “high rates of suicide among transgender people who have medically transitioned (Dhejne et al., 2011).” This study is widely cited in anti-transgender media (Williams, 2015) as evidence that gender-affirming surgery is ineffective, despite its own finding that “no inferences can be drawn as to the effectiveness of sex reassignment as a treatment” (Dhejne et al., 2011, p. 7). A follow-up analysis reported that fewer than 1 in 40 participants (in statistical terms) regretted their transition (Dhejne, Öberg, Arver, & Landén, 2014), and the first author has given multiple interviews discussing the misrepresentation of her work (Dhejne, 2017; Williams, 2015). The body of evidence that supports allowing adolescents to access treatment for puberty suppression (Costa et al., 2015; de Vries et al., 2014) and adults to access hormone replacement therapy and/or gender-affirming surgery (Heylens, Verroken, De Cock, T’Sjoen, & De Cuypere, 2014; Johansson, Sundbom, Höjerback, & Bodlund, 2010; Ruppin & Pfäfflin, 2015; van de Grift et al., 2017) continues to grow.

Marchiano shows open dismay at the fact that youth are identifying as transgender at all, calling it “a significant psychic epidemic,” expressing fear that “adopting a transgender identity has become the newest way for teen girls to express feelings of discomfort with their bodies,” and even claiming (without attribution) that “many in the lesbian community are distraught to notice that butch lesbians are quickly disappearing,” presumably due to coming out as transgender men (2017b, pp. 346, 348, 350). She warns against allowing transgender children to undergo social transition because of the “significant risk of progressing to medical transition” (p. 352, emphasis added), perpetuating the same outdated view of transition itself as a negative outcome (Nelson, 2016) that the medical and psychological establishments have historically adopted. And she concludes her literature review with three inaccurate claims in two sentences: “The first line of treatment for gender dysphoria involves invasive and permanent procedures [claim #1] for which there is scant evidence of their efficacy [claim #2]. And these treatments are easy to access [claim #3]” (2017b, p. 359). In reality, Coleman et al. (2012), de Vries & Cohen-Kettenis (2012), Deutsch (2016), and Sokkary et al. (2017) describe a broad spectrum of interventions, many of which are entirely non-medical; de Vries et al. (2014), Dhejne et al. (2014), and Hembree et al. (2017) are unequivocal regarding the benefits of those interventions; and James et al. (2016) and Vance et al. (2015) discuss the systemic barriers to care that make allegations of too-easy access especially—and cruelly—ironic. One begins to wonder which phenomenon is the true social contagion: gender dysphoria in adolescence, or the moral panic surrounding it?

Context and Impacts

NOTE: This section does not appear in the published article.

“Outbreak” might be dismissed as a single case of hasty scholarship or mistaken reliance on the writings of an outspoken minority, if not for the alarming clinical advice Marchiano dispenses on her professional blog. She encourages parents of transgender children “to share their opposing views,” calling this explicit rejection “an important intervention that helps lead to desistance” (2017a, emphasis added), contrary to the growing body of research showing that familial support and affirmation are critical to health outcomes for transgender youth and adults (James et al., 2016; Klein & Golub, 2016; Olson, Durwood, DeMeules, & McLaughlin, 2016; Simons, Schrager, Clark, Belzer, & Olson, 2013). In another post, Marchiano counsels a teenager with gender dysphoria: “I’m going to be forthright and tell you that, in my opinion, it would be better to avoid taking testosterone,” calling it “a pharmacological answer for a question of the soul” and warning about dangerous side effects with no mention of the well-documented potential benefits (2017c).

Such an emphasis on desistance takes on a sinister aspect in light of survey data revealing that transgender adults cite parental pressure as the most common reason for de-transitioning, over seven times more frequent than “realiz[ing] that gender transition was not for them” (James et al., 2016, p. 111). Marchiano’s recommended course of action resembles clinical observations of abusive parents who “portray to their children (and others) that they are doing all they can to support them, and the child is simply being overly demanding if they ask for specific gender-related things” (Riggs & Bartholomaeus, 2018). Enabling such parental behavior is inconsistent with promoting “an end to the use of reparative or conversion therapies by professional social workers” (National Association of Social Workers, 2018, p. 328) and with Marchiano’s professional obligations to “respect and promote the right of clients to self-determination,” to “base [her] practice on recognized knowledge,” and to “act to prevent and eliminate domination of, exploitation of, and discrimination against any person, group, or class on the basis of . . . gender identity or expression” (National Association of Social Workers, 2017, pp. 7, 25, 30).

Postscript

NOTE: This section does not appear in the published article.

This article was accepted for publication in August 2018. Later that month, PLoS ONE published Littman’s 2017 work on “rapid-onset gender dysphoria” (2018a); Marchiano was credited in the article’s acknowledgments. A polarizing online debate ensued in which Marchiano engaged biologist and activist Julia Serano (Serano, 2018a, 2018b; D’Angelo and Marchiano, 2018), among others, regarding allegations of transphobic bias on Littman’s part. Serano’s response is more comprehensive and much better written than this article.

PLoS ONE initiated a post-publication review in response to this debate and other criticism. In March 2019, the journal issued a correction notice (Littman, 2019), a significantly revised article (Littman, 2018b), a formal comment on the study’s methodology (Costa, 2019), and an apology to the trans and gender-variant communities (Heber, 2019) for the failure of peer review that led to the article being published in its original form. Littman claimed vindication later that day in an interview with the online magazine Quillette (Kay, 2019a), which has made a name for itself in recent years by attacking “transgender ideology,” “grievance studies,” and other cultural boogeymen. (Marchiano has published five articles in Quillette as of March 2019.)

Littman’s interviewer later claimed that “trans rights need to be balanced against other rights, including that of women to be safe” (Kay, 2019b). This position is easily mistaken for a nuanced one, but it rests on an unspoken denial that those rights are one and the same for millions of people, including this author. By donating airtime and page space to those who deny that fact, otherwise well-intentioned bystanders routinely force trans people to debate our own existence.

And it is exhausting.