gender dysphoria transgender
A year ago, as a result of a blog post I wrote, I began offering consultations to parents of teens who had announced "out of the blue" that they were transgender. Each week, several new families made contact with me, and their stories are remarkably similar to one another. Most have 14 or 15-year-old daughters who are smart, quirky, and struggling socially. Many of these kids are on the autism spectrum. And they are often asking for medical interventions - hormones and surgery - that may render them sterile, affect their liver, or lead to high blood pressure, among other possible side effects.

The parents are bewildered and terrified, careful to let me know that they love their child and would support any interventions that were truly necessary. They speak to me of dealing with their fear for their child in terrible isolation, as friends and family blithely celebrate their child's "bravery."

I am overwhelmed by the sheer volume of parents who call me. I find it difficult to listen to their stories - each one so like the others. The desperation in their voices is palpable. They ask if they can fly to see me and bring their daughter. When I tell them I don't do that, they ask if I can direct them to any therapist who won't just affirm and greenlight their child for medical transition. Their voices are tremulous with relief at speaking with someone who doesn't dismiss their concerns about unnecessary medical interventions. Each consultation lasts longer than the time I have allotted for it.

At times, I am able to offer advice that helps a family steer their child clear of drastic medical intervention of dubious benefit or necessity. But sometimes all I can do is stand helpless and witness the wreckage. Claire's story was one of the latter.

Like many of the young people I hear about, Claire's daughter Molly had had a series of complex medical and psychological challenges as an adolescent. Though profoundly gifted, the teenager struggled with autism, dyspraxia, and anxiety, all of which made school challenging. At 13, Molly developed anorexia, for which she was hospitalized twice. "There were years in there where I felt like my job was just to keep her alive," Claire explained. Thanks in part to intensive psychotherapy, Molly had mostly recovered from the eating disorder by age 16, only to face new medical problems - she was diagnosed with Crohn's disease. Managing this condition required doctor visits and medications, some of which came with worrying side effects. It also added to Molly's isolation and social struggles.

Despite her multiple challenges, Molly finished high school on time, and was accepted at her first-choice college. Claire and her husband Jeff felt relieved. But after graduation came a new diagnosis. On her 18th birthday, after spending much of the summer online, Molly told her parents that she was transgender.

This news came as a shock. According to Claire, Molly had never before expressed any concerns about gender. She had been a fairly typical little girl in terms of interests and play choices, and had dated several boys in high school. Nevertheless, Jeff and Claire didn't object when Molly traded her long hair for a buzz cut. They even purchased a binder for her that would flatten her chest and make her look more male. Hoping that a therapist could help Molly clarify her feelings about gender, Claire and Jeff accompanied her to an intake appointment at a gender clinic. Claire was shocked by what happened there.

After a 30-minute consultation with a physician's assistant, Molly was given an appointment for the following week to begin testosterone injections. There was no exploration of her other physical and mental health issues, and whether these may have influenced her belief that she was trans. There was also no caution expressed about how hormone treatment might affect Crohn's disease. Molly simply had to sign a consent form stating that she identified as male and understood the risks associated with testosterone.

The PA (physician assistant) also suggested that Molly schedule top surgery - a double mastectomy - within a few months. When Claire stated that she and Jeff wanted time to do research and consider alternatives before allowing Molly to begin taking testosterone or have surgery, the PA told her that their job as parents now was to support and affirm their 'son.' In front of Molly, he told Claire she ought to get her own therapist to deal with her issues so that she could be a better support person to 'Max.' When Claire and Jeff expressed concerns about Molly's anxiety and isolation, the PA stated that these were likely a result of Molly being transgender, and would resolve once she began to transition.

Up until about ten years ago, gender dysphoria presenting for the first time in adolescence was virtually unknown in natal females. (There is a well-known type of gender dysphoria found in males that sometimes begins in adolescence.) In the prototypical form of female gender dysphoria, signs first appear in early childhood, usually between the ages of two and four. Such girls hate stereotypic femininity - such as Barbies and dresses - and embrace stereotypic masculinity-such as short hair, pants, and toy guns. For most young children whose gender dysphoria began well before puberty, feelings of discomfort with their natal sex resolve on their own, usually before adolescence. The exact proportion of childhood-onset cases whose gender dysphoria persists into adolescence and young adulthood has been estimated to be approximately 20%.

In the past decade, however, a new presentation of gender dysphoria has suddenly become widespread, in which teens or tweens come to identify as transgender "out of the blue," without any childhood history of feeling uncomfortable with their sex. Experts have dubbed this presentation rapid onset gender dysphoria, and are beginning to study it.

"We think this is an entirely distinct phenomenon from childhood-onset gender dysphoria," says Michael Bailey, PhD a leading researcher on sexuality and gender, and a psychology professor at Northwestern University. "Indeed, we think it didn't exist until recently. It is a socially contagious phenomenon, reminiscent of the multiple personality disorder epidemic of the 1990s."

Although not much is known at this time about ROGD, it appears likely that it may be a kind of social contagion in which young people - often teen girls - come to believe that they are transgender. Preliminary research indicates that young people who identify as trans "out of the blue" may have been influenced by social media sites that valorize being trans. In addition, researchers have observed a pattern of clusters of friends coming out together.

While transgender advocates have derided the notion that the sudden surge in trans identified teens - and natal female teens in particular - could be influenced by social contagion, the idea is not so far-fetched. Bulimia was virtually unknown until the 1970s, when British psychologist Gerald Russell first described the condition in a medical journal. Author Lee Daniel Kravetz interviewed Russell for his recent book Strange Contagion. According to Russell, "once it was described, and I take full responsibility for that with my paper, there was a common language for it. And knowledge spreads very quickly." Scientists have been able to track bulimia's transmission even into culturally remote enclaves following the introduction of Western media sources. It is estimated that bulimia has since affected 30 million people.

Others have noted that rapid onset gender dysphoria may share much in common with another social contagion that spread symptoms of mental distress which were iatrogenic - that is, created or reinforced by the process of receiving medical or mental health treatment. In the 1990s, some therapists unwittingly encouraged their patients to construct false narratives of having been sexually abused. These patients often became identified with their role as a victim, found themselves dependent on their therapist, and saw a decline in their functioning and overall mental well-being.

While many in the research community are gaining a growing awareness of rapid onset gender dysphoira and its contagious nature, clinical practice guidelines have not caught up with this newer understanding. Moreover, in recent years, advocacy on behalf of the transgender community has seen medical gatekeeping reduced so that, in many places in the US, young people like Molly can access medical transition without any diagnostic or assessment process.

This is concerning, because there is reason to suspect that those with rapid onset gender dysphoria are unlikely to benefit from medical transition, and may even be harmed by it. Studies indicate that teen girls with this type of dysphoria have much higher rates of serious mental health issues than those with the more common gender dysphoria that is first noticed in early childhood. The growing community of detransitioners - mostly young women in their 20s - suggests that loosening the standards for accessing medical transition hasn't served everyone well.

In Molly's case, Claire and her husband wanted to be tolerant and accepting of Molly's exploration of gender, but were alarmed by the rush to medical intervention. As a medical professional with a research background, Claire was worried about the side effects of testosterone. Research quickly confirmed what she suspected - there are no studies on the long-term safety of testosterone in female bodied people, and little is known about how testosterone might affect Molly's medical and mental health conditions. Furthermore, some of testosterone's effects - such as a deepened voice and growth of facial hair - are permanent. Claire and Jeff were concerned enough by the lack of science supporting medical transition for someone in Molly's situation that they asked their daughter to move slowly so that they could all do more research. At first, Molly agreed.

However, shortly after Molly started college, Claire could tell that all was not well. Molly communicated with her parents infrequently. When Claire managed to reach her, Molly was withdrawn and sullen. By October, Molly stopped responding to phone calls, and would only communicate by text. A week before Molly was due to come home for Thanksgiving, Claire and Jeff received a call that Molly had been admitted to a psychiatric ward after becoming erratic and violent in her dorm.

When Jeff and Claire arrived the next morning after driving through the night, they were distraught by what they found. Molly seemed like a different person than the kid they had dropped off just a few months before. When she saw her parents, she became agitated. "She kept repeating that she didn't want to see us, that we were the reason she had been hospitalized because we didn't support her transition," explained Claire. Eventually, hospital staff asked Jeff and Claire to leave.

Claire believes that Molly's aggression and volatility were a reaction to beginning testosterone injections, which had commenced two weeks prior to the hospitalization. Molly had also changed her name and gender designation at school. A gender-affirming therapist at her college counseling center had referred her to an informed consent clinic for the testosterone prescription.

The rest of Molly's story is not a happy one. At the end of her freshman year, she had top surgery, paid for by student health insurance. She moved back home over the summer so that her parents could help during her recovery. By this time, Molly's voice had deepened, facial hair had grown in, and she passed as male full-time. Molly had become Max.

In spite of having transitioned, Max did not blossom into his "authentic self." In fact, his mental health worsened. He was more anxious and isolated than ever and rarely left the house, spending most of his time online. He told his mother that he feared people would know he was trans and try to harm him were he to go out in public. When Claire tried to reassure him by offering to accompany him, Max often refused, expressing a lack of trust for Claire and her motives because, in Max's words, Claire was a "transphobe." "I feel as though my child has been taught to be paranoid about me," Claire told me.

By the end of that summer, Max had yet another diagnosis to contend with. He began experiencing symptoms of interstitial cystitis, a painful and often debilitating condition that affects the bladder. Claire was not able to find any discussion in the medical literature about testosterone use and interstitial cystitis, but she did find online accounts of trans men suffering from worsening IC symptoms after going on testosterone. Claire pointed out that we just don't know enough about how these medications affect people long-term. "I would say these gender doctors are experimenting on people," Claire told me, "but when you experiment, you keep data and track outcomes."

When Claire and I last spoke, Max was still living at home. Between his anxiety and his symptoms of IC, he had been unable to return to college. The only times he left the house were to see his therapist or attend a trans support group.

Claire agrees. "Molly's belief that she was trans was a maladaptive coping mechanism she used to deal with her anxiety and other issues," she said. "That belief was reinforced by her peers online and at college, by the therapist at school, and the providers at the gender clinic. These people not only encouraged her to believe that she was trans, but also that she needed to transition medically or risk being unhappy and suicidal. And once she had transitioned, there was an online community encouraging her to believe that the world would hate her because she is trans. They have sealed her in a cave, and I fear there may be no way back."

Claire's story is not unique. The spiking numbers of teens seeking gender reassignment throughout the developed world have some experts concerned that we are seeing another widespread contagion. In the UK, Australia, and US, the number of teens seeking treatment has soared. The website 4thwavenow, which describes itself as "a community of parents and friends skeptical of the transgender child/teen trend," gets around 60,000 views per month, and the comments section is filled with hundreds of stories every bit as harrowing as Claire's.

What will it take for this contagion to be seen for what it is, so that its most damaging effects can be prevented? Recently, one mom told me that I was her only hope. She surely deserves better than that.

Claire's story has been used with permission. Names and all identifying details have been changed to protect privacy.