A New Cohort of Transgender Kids

We need to work out how to properly care for them. That means changing the debate.

Teenagers walk in the streets of Sundbyberg near Stockholm. Sweden, the world’s first country to recognise transgender rights, has begun restricting gender hormone treatments for minors. (Jonathan Nackstrand/AFP via Getty Images.)

By Lisa Selin Davis

For many of them, it became obvious around 2015. That’s when pediatricians like Dr. Julia Mason in Oregon, or child psychiatrists like Riittakerttu Kaltiala-Heino in Finland, could see that the young people suffering from gender-related distress, coming out as transgender, or self-diagnosing with gender dysphoria, were nothing like the kids they thought they’d be seeing.

As gender care and the number of patients seeking it expanded, they expected to see kids like those in the “Dutch studies,” the original research on which youth gender medicine is based. Those kids, followed in the 1990s and early 2000s, had medically transitioned with puberty blockers, cross-sex hormones and surgeries—what became known as the “Dutch protocol.” They seemed, at the time, to have recovered remarkably well from gender dysphoria. Those presenting at clinics back then were mostly, but not all, natal boys. They’d suffered from lifelong gender dysphoria but not from other mental illnesses, and they lived in supportive families. That is, those kids “were considered good candidates for a difficult path,” Mason told me.

The Dutch protocol officially came to America in 2007 when the first pediatric gender clinic opened at Boston Children’s Hospital. Soon after, the profiles of trans kids rose in the media. Kids learned about gender identity in school, and could select a gender identity like neutrois or pangender from a drop-down menu on social media. More clinics opened around the country, and the protocol shifted slightly, favoring the idea of affirmation—affirming a child’s self-proclaimed gender identity—above careful evaluation over a long period.

Then the demographics of kids seeking care shifted, too.

Beginning in the 2010s, clinicians began to see more teen girls, with no history of gender distress and plenty of other psychiatric issues, present for treatment. Some were like Chloe Cole or Prisha Mosley: girls depressed and alienated from their bodies (and from other girls) coming out as trans despite no previous gender issues. Some had endured sexual assault or other traumas before coming out.

This trajectory was noted by one of the great progenitors of affirmative care, Diane Ehrensaft. “There are also children who suddenly show up with a gender issue after a trauma,” she wrote in 2011. “Here, too, we may be seeing children who are expressing other troubles through gender.”

The new, rarely-before seen cohort was found in countries from England to Canada. It was documented in peer-reviewed academic papers. France’s National Academy of Medicine wrote that “Whatever the mechanisms involved in the adolescent—overuse of social networks, greater social acceptability, or example in the entourage—this epidemic-like phenomenon results in the appearance of cases or even clusters in the immediate surroundings.”

In many places, this change worried clinicians, because the original Dutch research “doesn’t apply to the current cohort,” Mason said. “Those were different kids.” 

“The guidelines were written for what we thought was a smaller group of patients and also more homogeneous than we actually see,” confirmed Thomas Lindén, Director of Knowledge-Based Policy of Health Care at Sweden’s National Board of Health and Welfare.

One concern was that if these kids’ gender identities were affirmed, their other troubles would be ignored—assumed to be symptoms of gender dysphoria, when there was evidence that for some kids, the mental health problems may be its cause. Many of the kids suffered from conditions like anorexia, borderline personality disorder, or depression, which were pushed aside rather than treated under the affirmative model.

That “diagnostic overshadowing” was one reason England revised its guidelines away from the American affirmative model, relegating the use of puberty blockers to clinical studies. Countries like Sweden and Finland set about shifting their guidelines for treating gender dysphoric youth, concluding that puberty blockers and hormones may do more harm than good. Recently, Denmark and France have been heading toward this more cautious route, too.

But as other countries conducted systematic evidence reviews and demanded long-term follow-up, America traveled a different path. Just over five years ago, in 2018, Dr. Lisa Littman published a peer-reviewed paper about clusters of these teen girls coming out, often after social media exposure. She coined a neutral term to describe the phenomenon: rapid-onset gender dysphoria (ROGD).

Most of the American medical community didn’t react with the kind curiosity or concern some European clinicians showed. Instead, they denied and discounted not only the research, but the researcher. “Littmanian” is now a dismissive insult among certain activists. The American media and medical establishment generally spoke about ROGD only to dissuade people from accepting it. In 2021, the Coalition for the Advancement & Application of Psychological Science published a letter arguing that the concept of ROGD has the “potential for creating harm.”

A major sticking point in the ROGD controversy is the lack of sound research. Earlier this year, a paper about ROGD was published by sex researcher and Northwestern psychology professor J. Michael Bailey and a parent going by the pseudonym Suzanna Diaz. Based on 1774 responses from mostly liberal parents, the paper noted that “The demographics of gender dysphoria have changed dramatically during the past two decades.” Most of the children cataloged were female, and many respondents said their children had other mental health issues. The paper was heavily criticized by some LGBT advocacy groups, gender-affirming clinicians and researchers, whose concerns included the fact that it didn’t properly engage with the critiques of ROGD—that is, it took too seriously the phenomenon it was investigating. (In the end Springer took the rare and serious step of retracting the paper, not because of its quality, but because the survey participants hadn’t known their responses would appear in an academic publication, not just on a website.)

Bailey and Diaz admit their study’s limitations. The sample is biased; parents were recruited from a website for believers in ROGD, and didn’t include affirming parents who don’t believe in ROGD, or children themselves. These are the kind of limitations—biased, self-selected samples—that plague most of gender research. Some researchers have begun to question the legitimacy of the Dutch research itself.

That’s why we need more research, and for it to be better quality. Because at this point, there should be no question that this cohort exists—and that we don’t know the proper way to care for it. I know this personally because I’ve been talking to these kids and their parents, as well as to concerned clinicians and trans people, for six years (I’m working on a book about the youth gender culture war­.) It’s clear in the rising prominence of detransitioners, who were affirmed and medically transitioned and later felt it was a mistake; their bodies are permanently changed, often damaged. By one estimate, this feeling of regret can take an average of about eight years to develop, so it makes sense that we’re hearing from more of them after the 2015 spike in cases of gender dysphoria.

Both Cole and Mosley, two of the girls who transitioned, went on to detransition after having their breasts removed and taking testosterone, leading to medical problems like vaginal atrophy. Both have launched lawsuits, as have several others like them who feel they were failed by the affirmative model. No one knows the number of detransitioners, or the true rate of regret among the new cohort. That’s because of the lack of long-term follow-up and because “detransition,” like rapid-onset gender dysphoria, is so politicized a term that there is more of an attempt by American clinicians to discredit it than to study it.

What we do know is that a new and different cohort is transitioning, and that we haven’t cataloged their outcomes. We need to follow Europe’s lead: engaging in open inquiry and expanding the evidence base. For that, we need to depoliticize the term rapid-onset gender dysphoria. As Bailey and Diaz conclude: “all stakeholders in this controversy ultimately have the same goal: the long-term happiness of gender dysphoric youth.”

Lisa Selin Davis is a journalist, and the author of Tomboy: The Surprising History & Future of Girls Who Dare to Be Different.

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