Rapid-onset gender dysphoria controversy

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The rapid-onset gender dysphoria controversy centers around the concept of rapid-onset gender dysphoria (ROGD), proposed to be a subtype of gender dysphoria caused by peer influence and social contagion.[1] It is not recognized by any major professional association as a valid mental health diagnosis, and its use has been discouraged by the American Psychological Association, the American Psychiatric Association, the World Professional Association for Transgender Health, and other medical organizations due to a lack of reputable scientific evidence for the concept.[2][3]

Lisa Littman, as an adjunct assistant professor at the Icahn School of Medicine at Mount Sinai, created the term based on an online survey of parents on three anti-transgender websites who believed that their teenage children had suddenly manifested symptoms of gender dysphoria and begun identifying as transgender simultaneously with other children in their peer group.[4][5][6] Littman speculated that rapid onset of gender dysphoria could be a "social coping mechanism" for other disorders.[1]

In August 2018, Littman (then an assistant professor of the practice at the Brown University School of Public Health) published a descriptive study in PLOS One.[1] Criticism of the study's methodology and conclusions was voiced by some clinicians, researchers, and transgender activists, and two weeks after publication, PLOS One responded by announcing a post-publication review of the paper.[7][8] On the same day as PLOS One announced its post-publication review, Brown University retracted its press release promoting the study.[7] Controversy surrounding the paper grew as articles and opinion pieces, both critical and supportive, were published in mainstream media discussing concerns about the study's methodology and the validity of its hypotheses,[8][9][10] as well as issues of academic freedom.[7][11]

In March 2019, the journal concluded its review and republished Littman's revised and corrected version.[12] Other researchers have since remarked on a much increased incidence of youth seeking care for dysphoria, the cause of which remains to be established.[13][14][15]

In 2021, the American Psychological Association and the American Psychiatric Association cosigned a statement with 120 other medical organizations calling for ROGD not to be used in diagnostic or clinical settings due to a lack of reputable scientific evidence for the concept. The statement also criticized the proliferation of misinformation supporting the concept of ROGD targeted at parents and clinicians and the concept's use to justify laws targeting the rights of transgender youth in the United States.[3]

A November 2021 study published in the Journal of Pediatrics analyzed clinical data of teenagers seen in gender clinics and found no support for ROGD being a distinct phenomenon. The authors found no link between more recent onset of gender dysphoria and other mental health problems, and no link between recent onset and a high level of support from online or transgender friends.[16]

Original publication[edit]

Lisa Littman, an American physician and researcher, coined the term "rapid-onset gender dysphoria" at the outset of her research for a descriptive study originally titled "Rapid-onset gender dysphoria in adolescents and young adults: A study of parental reports".[17] Littman's medical specialties are in preventive medicine and public health, as well as obstetrics and gynecology.[18] Her research interests relate to reproductive health, gender dysphoria, detransition, and maternal and child health including prematurity and the use of substances in pregnancy.[18] Littman joined the faculty of the Brown University School of Public Health in 2018 as Assistant Professor of the Practice in Behavioral and Social Sciences.[18]

Littman, then an adjunct assistant professor at the Icahn School of Medicine at Mount Sinai, became interested in the possible role of social contagion in gender dysphoria among young people, and conducted a study by collecting 256 responses from an online survey, which was not randomly distributed, but rather targeted at parents recruited from three anti-transgender websites where she had seen parents describe what they believed were sudden gender transitions in their adolescents: 4thWaveNow, Transgender Trend, and Youth TransCritical Professionals.[8][4][5][6] Littman said she encouraged wide distribution of the survey beyond these three sites,[8] but the study states that participants were encouraged to distribute the study only to "individuals or communities that they thought might include eligible participants," which the study defined as parents who believed "their child had a sudden or rapid onset of gender dysphoria," thus using another nonprobability sampling method known as "snowball sampling."[1] Of the three websites, an article published in Science described the first two as "gathering places for parents concerned by their children's exploration of a transgender identity", with the third being closed to non-members.[8] Bioethicist Florence Ashley described the first as "dedicated to opposing gender-affirmative care for trans youth", and the latter two as dedicated to opposing what they call "trans ideology".[19]

More than three-quarters of the parents surveyed had rejected their child's transgender identity. Arjee Restar, a behavioral health researcher then also at the Brown School of Public Health, wrote that the three sites were frequented by parents who already specifically promoted the concept of ROGD and that the websites were "known for telling parents not to believe their child is transgender".[20]

Littman's study described what the surveyed parents believed to be a rapid onset of gender dysphoria among their children,[8] along with information the parents reported about their children's peer group dynamics, social media use, and prior mental health issues.[21] Littman speculated that rapid onset of gender dysphoria could be a "social coping mechanism" for other disorders, such as depression and anxiety caused by adolescent trauma.[1] Littman presented preliminary results at a 2017 conference, and the descriptive study was initially published in PLOS One in August 2018.[1][8]

Correction[edit]

The paper was met with criticism from health researchers, transgender activists, and others, who stated that it had already been politicized, and that there was self-selection bias of the subjects that Littman surveyed, as she only surveyed parents and not the young people themselves nor the health professionals caring for them.[8][10][20] Responding to negative comments, PLOS One announced two weeks after publication that it would open a post-publication review of the study's methodologies and analyses.[7][8][20][22]

In March 2019, PLOS One completed its post-publication review, and Littman's corrected version of the paper was published on March 19, 2019.[23] In the journal's blog, PLOS One editor Joerg Heber apologized "to the trans and gender variant community" for the previous review and publication, saying "the study, including its goals, methodology, and conclusions, were not adequately framed in the published version, and that these needed to be corrected."[24] Heber noted that the hypothesized condition of ROGD had "not yet been clinically validated."[24]

In a notice of correction prefacing her updated version of the study, Littman stated:

[T]he post-publication review identified issues that needed to be addressed to ensure the article meets PLOS ONE's publication criteria. Given the nature of the issues in this case, the PLOS ONE Editors decided to republish the article, replacing the original version of record with a revised version in which the author has updated the Title, Abstract, Introduction, Discussion, and Conclusion sections, to address the concerns raised in the editorial reassessment. The Materials and methods section was updated to include new information and more detailed descriptions about recruitment sites and to remove two figures due to copyright restrictions. Other than the addition of a few missing values in Table 13, the Results section is unchanged in the updated version of the article.[12]

PLOS One's editor wrote that "the corrected article now provides a better context of the work, as a report of parental observations, but not a clinically validated phenomenon or a diagnostic guideline".[24] On behalf of the journal, Heber wrote, "Correcting the scientific record in this manner and in such circumstances is a sign of responsible publishing", where further scrutiny was called for to "clarify whether the conclusions presented are indeed backed up by the analysis and data of that original study."[24] Heber later stated, "At its core, the survey of the parents stands as it is... We let the original results stand."[23]

Terminology[edit]

The term "rapid-onset gender dysphoria", coined by Littman, first appeared in a July 2016 notice that was posted on four websites, recruiting parents to respond to a research survey that Littman described as "Rapid onset gender dysphoria, social media, and peer groups".[25] In the title of Littman's poster abstract for the study, published in February 2017, the phrase appeared as "Rapid Onset of Gender Dysphoria".[26]

Littman notes that "Rapid-onset gender dysphoria (ROGD) is not a formal mental health diagnosis at this time."[12] She wrote:

This study of parent observations and interpretations serves to develop the hypotheses that rapid-onset gender dysphoria is a phenomenon and that social influences, parent-child conflict, and maladaptive coping mechanisms may be contributing factors for some individuals. ... This report did not collect data from the adolescents and young adults (AYAs) or clinicians and therefore does not validate the phenomenon.[12]

In a formal comment published by PLOS One at the conclusion of its review, Angelo Brandelli Costa wrote, "the level of evidence produced by the Dr. Littman's study cannot generate a new diagnostic criterion relative to the time of presentation of the demands of medical and social gender affirmation."[27] Costa suggested, "Several procedures still need to be adopted to generate a potential new subcategory of gender dysphoria that has not yet been clinically validated. One of these procedures is the assessment of mental health professionals trained according to the World Professional Association for Transgender Health (WPATH) and the American Psychological Association (APA) guidelines, interviewing not just the family, but the youth (longitudinally)."[27]

Reactions[edit]

Institutional[edit]

On the same day that PLOS One announced its review, Brown University took down a press release it had earlier posted about the paper.[7][28] Responding to critics, Brown University president Christina Paxson and Provost Richard M. Locke said they had not infringed on academic freedom and stated that Brown's commitment to only "publicize research that unassailably meets the highest standards of excellence" required Brown to retract the press release after PLOS One opened an investigation on the paper in question.[29] They said that "given the concerns raised about research design and methods, the most responsible course of action was to stop publicizing the work published in this particular instance. We would have done this regardless of the topic of the article."[30]

Social and political commentary[edit]

Several critiques of sociological aspects of the study have been published in peer-reviewed journals. In a 2020 paper published in The Sociological Review, bioethicist Florence Ashley described the study as an attempt to circumvent existing research supporting gender-affirming care.[31] Sociologists Natacha Kennedy and Victoria Pitts-Taylor, in two separate 2020 publications in the Journal of LGBT Youth and Sexualities, described ROGD as a moral panic and argued that trans youth are often aware of their identity long before coming out to their parents.[32][33]

Publications such as The Conversation and Slate condemned what they saw as politicization of science by social conservatives,[10][34] while Madeleine Kearns, a contributing writer at National Review, called for further study into the proposed phenomenon.[35] Writer and transgender advocate Liz Duck-Chong described the hypothesized condition as "a poisonous lie used to discredit trans people" in the op-ed section of The Guardian,[9] while Abigail Shrier, who later published the controversial book Irreversible Damage about the concept, called it an explanation for the experiences of parents in the op-ed section of The Wall Street Journal.[21][36][37][38]

In a Psychology Today opinion piece, Rutgers University psychology professor Lee Jussim described the PLOS-mandated rewrite of the paper as an "Orwellian correction" involving some additions and minor changes where no errors had existed.[39] Jeffrey Flier, a former dean of Harvard Medical School, said that Brown was valuing diversity over academic freedom and called the retraction a "cautionary tale" about pressure from social media, calling for a movement to support academics conducting controversial research.[11]

Academic[edit]

Shortly after PLOS One published the corrected study, a critique of the original study's methodology appeared in Archives of Sexual Behavior.[20] The author, Arjee Restar, argued that Littman's study was fatally methodologically flawed, beginning with the choice to sample exclusively from users of three websites "known for telling parents not to believe their child is transgender," with the result that three-quarters of those surveyed had rejected their child's gender identity; 91 percent of respondents were white, 82 percent were women, and 66 percent were between the ages of 46 and 60. She wrote that the study was mostly composed of "white mothers who have strong oppositional beliefs about their children’s trans identification" and that there was very little evidence that Littman's survey responses were representative of trans youth and young adults as a whole.[20]

In a letter to the editor, Littman responded by arguing that her methodologies were consistent with those that had been used, without controversy, in widely-cited studies supporting gender identity affirmation health care.[40]

Some clinicians state that an increasing prevalence of trans youth first presenting in early adolescence, as described in Littman's research, is consistent with their patient population, though they are uncertain as to causes or implications for clinical treatment.[14][15][41] In a 2020 commentary in Pediatrics, citing Littman's paper among others, Annelou de Vries wrote that gender identity development was diverse and and called for more research into this demographic cohort.[13]

Professional commentary[edit]

Following publication of the original report in PLOS One, the World Professional Association for Transgender Health (WPATH) released a position paper on the proposed term "rapid-onset gender dysphoria" and the research, stating that the term is not recognized by any professional association, nor listed in the DSM or ICD lists of disorders and diseases. They said in summary "it is nothing more than an acronym created to describe a proposed clinical phenomenon that may or may not warrant further peer-reviewed scientific investigation." They affirmed the need for academic freedom and scientific exploration without censorship, and that much is still unknown about the factors contributing to the development of gender identity in young people, and said it was "premature and inappropriate" to use "official-sounding labels" that might influence professionals or the public to reach conclusions about how or when adolescents decide to come out as transgender.[2][42] WPATH concluded by warning against the use of any term intended to cause fear about an adolescent's possible transgender status with the goal of avoiding or deterring them from accessing the appropriate treatment, in line with the Standards of Care appropriate for the situation.[2][42]

The Gender Dysphoria Affirmative Working Group (GDA) of 44 professionals involved in transgender health wrote an open letter to Psychology Today calling the study "methodologically flawed and unethical", saying it proceeded from "an overt ideological bias", and citing previously published criticism of the study stating that it had multiple biases and flaws in its methodology. They said the survey drew subjects from "websites openly hostile to transgender youth", and failed to account for this bias, instead basing its conclusions on the beliefs of surveyed parents who presupposed the existence of ROGD. Noting that Littman had not interviewed the teens, and had no experience working with transgender youth, the GDA criticized conclusions in the initial publication of the study about how teens arrived at a trans identity, saying onset may only have been "rapid" from parents' point of view because teens often delay coming out in hostile environments or when fearing criticism.[43][44]

The Pediatric and Adolescent Gender Dysphoria (GD) Working Group, a group of 20 professionals[45] who oppose the gender-affirming guidelines adopted by major medical organizations including WPATH, the Endocrine Society and American Academy of Pediatrics,[citation needed] said that ROGD warranted further study.[46][47][48][non-primary source needed] The group pointed to an increase in the number of teenagers coming out as transgender "without any significant prior history of gender dysphoria" and to both anecdotal reports and research indicating that many of them suffered from mental health disorders.[citation needed]

In 2021, the Coalition for the Advancement and Application of Psychological Science released a statement calling for the elimination of the concept of ROGD from clinical and diagnostic use, as "there are no sound empirical studies of ROGD and it has not been subjected to rigorous peer-review processes that are standard for clinical science." The statement also states that the term "ROGD" is likely to stigmatize and cause harm to transgender people, and that misinformation surrounding ROGD is used to justify laws suppressing the rights of transgender youth. The statement was cosigned by the American Psychiatric Association, the American Psychological Association, the Society of Behavioral Medicine, the Association for Behavioral and Cognitive Therapies, and the National Association of School Psychologists.[3]

Further research[edit]

A November 2021 study published in the Journal of Pediatrics examined data on a cohort of 173 trans adolescents from Canada to assess whether there was evidence for a rapid-onset pathway for gender dysphoria. The authors noted that while it was common to see adolescents presenting with gender dysphoria around puberty, in many cases patients had been aware of gender dysphoria from a younger age. The authors sought to establish whether there was any link between later awareness of gender ("rapid onset") and other factors including mental health problems, lack of parental support, and high level of support from online and/or transgender friends.[16] No evidence was found for any link between "rapid onset" and mental health problems, lack of parental support, or high level of support from online or transgender friends. Where relationships were found, they were in the opposite direction to that suggested by Littman's work—for instance, trans adolescents who had been dissatisfied with their gender for longer were more likely to suffer anxiety and more likely to misuse marijuana. The authors considered that they found no evidence of "rapid onset gender dysphoria" being a distinct clinical phenomenon.[16]

References[edit]

  1. ^ a b c d e f Littman, Lisa (August 16, 2018). "Parent reports of adolescents and young adults perceived to show signs of a rapid onset of gender dysphoria". PLOS ONE (March 19, 2019 corrected ed.). 13 (8): e0202330. doi:10.1371/journal.pone.0202330. PMC 6095578. PMID 30114286.
  2. ^ a b c WPATH Global Board of Directors (September 4, 2018). "WPATH Position on "Rapid-Onset Gender Dysphoria (ROGD)"" (PDF). WPATH. Retrieved 2019-05-30.
  3. ^ a b c "ROGD Statement". Coalition for the Advancement & Application of Psychological Science. Retrieved August 4, 2021.
  4. ^ a b Ashley, Florence (July 2020). "A critical commentary on 'rapid-onset gender dysphoria'". The Sociological Review. 68 (4): 779–799. doi:10.1177/0038026120934693. ISSN 0038-0261.
  5. ^ a b Bojanic, Sanja; Abadía, Mónica Cano; Moro, Valentina (2021-05-04). "Feminist responses to populist politics". European Journal of English Studies. 25 (2): 113–132. doi:10.1080/13825577.2021.1946741. ISSN 1382-5577.
  6. ^ a b "What rapid onset gender dysphoria really means". inews.co.uk. 2020-06-12. Retrieved 2022-01-09.
  7. ^ a b c d e "Reader outcry prompts Brown to retract press release on trans teens". Retraction Watch. August 29, 2018. Retrieved 2018-08-30.
  8. ^ a b c d e f g h i Wadman, Meredith (September 7, 2018). "'Rapid onset' of transgender identity ignites storm". Science. 361 (6406): 958–959. Bibcode:2018Sci...361..958W. doi:10.1126/science.361.6406.958. ISSN 0036-8075. PMID 30190384. S2CID 52169673. See also Wadman, Meredith (August 30, 2018). "News: New paper ignites storm over whether teens experience 'rapid onset' of transgender identity". Science. doi:10.1126/science.aav2613. ISSN 1095-9203. Archived from the original on 2018-08-31.
  9. ^ a b "Rapid-onset gender dysphoria' is a poisonous lie used to discredit trans people". The Guardian. London. October 22, 2018.
  10. ^ a b c "Why 'rapid-onset gender dysphoria' is bad science". The Conversation.
  11. ^ a b Flier, Jeffrey S. (August 31, 2018). "As a Former Dean of Harvard Medical School, I Question Brown's Failure to Defend Lisa Littman". Quillette. Archived from the original on 2018-09-23.
  12. ^ a b c d Littman, Lisa (March 19, 2019). "Correction: Parent reports of adolescents and young adults perceived to show signs of a rapid onset of gender dysphoria". PLOS ONE. 14 (3): e0214157. Bibcode:2019PLoSO..1414157L. doi:10.1371/journal.pone.0214157. PMC 6424391. PMID 30889220.
  13. ^ a b de Vries, Annelou L.C. (October 2020). "Challenges in Timing Puberty Suppression for Gender-Nonconforming Adolescents". Pediatrics. 146 (4): e2020010611. doi:10.1542/peds.2020-010611. ISSN 0031-4005. PMID 32958612.
  14. ^ a b Hutchinson, Anna; Midgen, Melissa; Spiliadis, Anastassis (January 1, 2020). "In Support of Research Into Rapid-Onset Gender Dysphoria". Archives of Sexual Behavior (Letter to the Editor). 49 (1): 79–80. doi:10.1007/s10508-019-01517-9. ISSN 1573-2800. PMID 31317286. S2CID 197541624.
  15. ^ a b Giovanardi, Guido; Fortunato, Alexandro; Mirabella, Marta; Speranza, Anna Maria; Lingiardi, Vittorio (2020-12-19). "Gender Diverse Children and Adolescents in Italy: A Qualitative Study on Specialized Centers' Model of Care and Network". International Journal of Environmental Research and Public Health. 17 (24): 9536. doi:10.3390/ijerph17249536. ISSN 1660-4601. PMC 7766564. PMID 33352745. With regards to the referrals, in line with international trends [9–12], Italian's population of trans* youths seem to be growing, particularly with respect to AFABs. Some respondents depicted referrals with traits of the so-called 'rapid onset' [15] of gender incongruence, especially when describing AFABs, with pressing requests to start soon hormone therapies and an (apparent) lack of history of gender incongruence. However, this is a very complex phenomenon that needs further exploration.
  16. ^ a b c Bauer, Greta R.; Lawson, Margaret L.; Metzger, Daniel L. (2021-11-15). "Do Clinical Data From Transgender Adolescents Support the Phenomenon of "Rapid-Onset Gender Dysphoria"?". The Journal of Pediatrics. doi:10.1016/j.jpeds.2021.11.020. ISSN 0022-3476. PMID 34793826. S2CID 244283360.
  17. ^ Littman, Lisa (August 16, 2018). "Rapid-onset gender dysphoria in adolescents and young adults: A study of parental reports". PLOS ONE. doi:10.1371/journal.pone.0214157.s001.
  18. ^ a b c "Lisa Littman: Assistant Professor of the Practice of Behavioral and Social Sciences". Researchers@Brown. Brown University. Archived from the original on 2018-08-19.
  19. ^ A critical commentary on ‘rapid-onset gender dysphoria’. Florence Ashley, The Sociological Review, August 10, 2020.
  20. ^ a b c d e Restar, Arjee Javellana (April 22, 2019). "Methodological Critique of Littman's (2018) Parental-Respondents Accounts of 'Rapid-Onset Gender Dysphoria'". Archives of Sexual Behavior. 49 (1): 61–66. doi:10.1007/s10508-019-1453-2. PMC 7012957. PMID 31011991.
  21. ^ a b Melchior, Jillian Kay (September 9, 2018). "Peer Pressure and 'Transgender' Teens". The Wall Street Journal. ISSN 0099-9660. Archived from the original on 2018-09-25.
  22. ^ "Brown University Statement — Monday, Aug. 27, 2018". August 22, 2018. Retrieved 2019-03-21.
  23. ^ a b Bartlett, Tom (March 19, 2019). "Journal Issues Revised Version of Controversial Paper That Questioned Why Some Teens Identify as Transgender". The Chronicle of Higher Education. ISSN 0009-5982. Retrieved 2019-03-19.
  24. ^ a b c d Heber, Joerg (March 19, 2019). "Correcting the scientific record on gender incongruence – and an apology". PLOS Blogs.
  25. ^ "Rapid-onset gender dysphoria: New study recruiting parents". 4thWaveNow. July 2, 2016. Archived from the original on 2018-03-09.
  26. ^ Littman, L.L. (February 2017). "Rapid Onset of Gender Dysphoria in Adolescents and Young Adults: a Descriptive Study". Journal of Adolescent Health. 60 (2): S95–S96. doi:10.1016/j.jadohealth.2016.10.369. Supplement 1.
  27. ^ a b Costa, Angelo Brandelli (March 19, 2019). "Formal comment on: Parent reports of adolescents and young adults perceived to show signs of a rapid onset of gender dysphoria". PLOS ONE. 14 (3): e0212578. Bibcode:2019PLoSO..1412578B. doi:10.1371/journal.pone.0212578. PMC 6424477. PMID 30889187.
  28. ^ Rudgard, Olivia (August 28, 2018). "Brown University in row with transgender activists over claims gender dysphoria spreading among children". The Telegraph. London. ISSN 0307-1235. Archived from the original on 2018-08-28.
  29. ^ Paxson, Christina (September 9, 2018). "Paxson '19, Locke '18: University committed to academic freedom, faculty support". The Brown Daily Herald. Brown University.
  30. ^ "Updated: Brown statements on gender dysphoria study". Expanded Brown University Statement – Tuesday, Sept. 5, 2018. News from Brown (Press release) (March 19, 2019 ed.). Providence, R.I.: Brown University. September 5, 2018. Archived from the original on 2019-03-27.
  31. ^ Ashley, Florence (July 1, 2020). "A critical commentary on 'rapid-onset gender dysphoria'". The Sociological Review. 68 (4): 779–799. doi:10.1177/0038026120934693. S2CID 221097476.
  32. ^ Kennedy, Natacha (September 10, 2020). "Deferral: the sociology of young trans people's epiphanies and coming out". Journal of LGBT Youth: 1–23. doi:10.1080/19361653.2020.1816244. S2CID 225241518.
  33. ^ Pitts-Taylor, Victoria (November 17, 2020). "The untimeliness of trans youth: The temporal construction of a gender 'disorder'". Sexualities. doi:10.1177/1363460720973895. S2CID 228846045.
  34. ^ "Criticism Is Not Censorship". Slate. 30 August 2018.
  35. ^ Kearns, Madeleine (January 19, 2019). "Rapid Onset Gender Dysphoria Should Be Investigated, Not Smeared". National Review. Archived from the original on 2019-01-29.
  36. ^ Valens, Ana (November 13, 2020). "Bari Weiss Defends Transphobic Book Pulled From Target". The Daily Dot.
  37. ^ Turner, Janice (December 30, 2020). "Irreversible Damage by Abigail Shrier review — resisting the 'transgender craze'". The Times. Archived from the original on December 30, 2020. Retrieved August 4, 2021.
  38. ^ Shrier, Abigail. "When Your Daughter Defies Biology". The Wall Street Journal. ISSN 0099-9660. Archived from the original on 2019-03-30.
  39. ^ Jussim, Lee (March 20, 2019). "Rapid Onset Gender Dysphoria: A saga of outrage and science reform". Psychology Today. Archived from the original on 2019-03-30.
  40. ^ Littman, Lisa (January 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 (Letter to the Editor). 49 (1): 67–77. doi:10.1007/s10508-020-01631-z. PMID 31953699. S2CID 210708422. Retrieved 2020-12-11.
  41. ^ Zucker, Kenneth J. (October 2019). "Adolescents with Gender Dysphoria: Reflections on Some Contemporary Clinical and Research Issues". Archives of Sexual Behavior. 48 (7): 1983–1992. doi:10.1007/s10508-019-01518-8. ISSN 0004-0002. PMID 31321594. S2CID 197663705.
  42. ^ a b Ashley, Florence (December 3, 2018). "There Is No Evidence That Rapid-Onset Gender Dysphoria Exists". PsychCentral. Retrieved 2019-05-30.
  43. ^ Adams, Noah; 43 others (December 1, 2018). "Psychology Today Response — Gender Dysphoria Affirmative Working Group". GDA. Retrieved 2019-06-03.
  44. ^ Dubreuil, Émilie (2019-05-13). "Je pensais que j'étais transgenre". ICI Radio-Canada (in French). Retrieved 2021-12-24.{{cite web}}: CS1 maint: url-status (link)
  45. ^ "Who We Are". Pediatric and Adolescent Gender Dysphoria Working Group. 2018. Archived from the original on 2018-08-03.
  46. ^ "The Gender Identity Phantom". Pediatric and Adolescent Gender Dysphoria Working Group. 2018. Archived from the original on 2018-08-03.
  47. ^ "American Academy of Pediatrics policy and trans- kids: Fact-checking". Pediatric and Adolescent Gender Dysphoria Working Group. 2018. Archived from the original on 2018-10-18.
  48. ^ "Rapid Onset Gender Dysphoria". Pediatric and Adolescent Gender Dysphoria Working Group. 2018. Archived from the original on 2018-08-03.