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RESEARCH ARTICLE
Parent reports of adolescents and young
adults perceived to show signs of a rapid
onset of gender dysphoria
Lisa LittmanID*
Department of Behavioral and Social Sciences, Brown University School of Public Health, Providence, Rhode
Island, United States of America
*Lisa_Littman@brown.edu
Abstract
Purpose
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. Parents describe that the onset of gender dysphoria seemed to occur in the con-
text of belonging to a peer group where one, multiple, or even all of the friends have become
gender dysphoric and transgender-identified during the same timeframe. Parents also report
that their children exhibited an increase in social media/internet use prior to disclosure of a
transgender identity. Recently, clinicians have reported that post-puberty presentations of
gender dysphoria in natal females that appear to be rapid in onset is a phenomenon that they
are seeing more and more in their clinic. Academics have raised questions about the role of
social media in the development of gender dysphoria. The purpose of this study was to collect
data about parents’ observations, experiences, and perspectives about their adolescent and
young adult (AYA) children showing signs of an apparent sudden or rapid onset of gender
dysphoria that began during or after puberty, and develop hypotheses about factors that may
contribute to the onset and/or expression of gender dysphoria among this demographic
group.
Methods
For this descriptive, exploratory study, recruitment information with a link to a 90-question
survey, consisting of multiple-choice, Likert-type and open-ended questions was placed on
three websites where parents had reported sudden or rapid onsets of gender dysphoria
occurring in their teen or young adult children. The study’s eligibility criteria included parental
response that their child had a sudden or rapid onset of gender dysphoria and parental indi-
cation that their child’s gender dysphoria began during or after puberty. To maximize the
chances of finding cases meeting eligibility criteria, the three websites (4thwavenow, trans-
gender trend, and youthtranscriticalprofessionals) were selected for targeted recruitment.
Website moderators and potential participants were encouraged to share the recruitment
information and link to the survey with any individuals or communities that they thought
PLOS ONE | https://doi.org/10.1371/journal.pone.0202330 August 16, 2018 1 / 44
a1111111111
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OPEN ACCESS
Citation: Littman L (2018) Parent reports of
adolescents and young adults perceived to show
signs of a rapid onset of gender dysphoria. PLoS
ONE 13(8): e0202330. https://doi.org/10.1371/
journal.pone.0202330
Editor: Daniel Romer, University of Pennsylvania,
UNITED STATES
Received: October 7, 2017
Accepted: August 1, 2018
Published: August 16, 2018
Copyright: ©2018 Lisa Littman. This is an open
access article distributed under the terms of the
Creative Commons Attribution License, which
permits unrestricted use, distribution, and
reproduction in any medium, provided the original
author and source are credited.
Data Availability Statement: The data cannot be
made available due to ethical and regulatory
restrictions. The study participants did not provide
consent to have their responses shared publicly,
shared in public databases, or shared with outside
researchers. The Program for the Protection of
Human Subjects (PPHS) at the Icahn School of
Medicine at Mount Sinai is not permitting the
sharing of data beyond what is reported in the
paper owing to the sensitive nature of the collected
information, the context of the study topic, its
release’s possible impact on the participants’
reputation and standing in the community, and the
might include eligible participants to expand the reach of the project through snowball sam-
pling techniques. Data were collected anonymously via SurveyMonkey. Quantitative find-
ings are presented as frequencies, percentages, ranges, means and/or medians. Open-
ended responses from two questions were targeted for qualitative analysis of themes.
Results
There were 256 parent-completed surveys that met study criteria. The AYA children
described were predominantly natal female (82.8%) with a mean age of 16.4 years at the
time of survey completion and a mean age of 15.2 when they announced a transgender-
identification. Per parent report, 41% of the AYAs had expressed a non-heterosexual sexual
orientation before identifying as transgender. Many (62.5%) of the AYAs had reportedly
been diagnosed with at least one mental health disorder or neurodevelopmental disability
prior to the onset of their gender dysphoria (range of the number of pre-existing diagnoses
0–7). In 36.8% of the friendship groups described, parent participants indicated that the
majority of the members became transgender-identified. Parents reported subjective
declines in their AYAs’ mental health (47.2%) and in parent-child relationships (57.3%)
since the AYA “came out” and that AYAs expressed a range of behaviors that included:
expressing distrust of non-transgender people (22.7%); stopping spending time with non-
transgender friends (25.0%); trying to isolate themselves from their families (49.4%), and
only trusting information about gender dysphoria from transgender sources (46.6%). Most
(86.7%) of the parents reported that, along with the sudden or rapid onset of gender dyspho-
ria, their child either had an increase in their social media/internet use, belonged to a friend
group in which one or multiple friends became transgender-identified during a similar time-
frame, or both
Conclusion
This descriptive, exploratory study of parent reports provides valuable detailed information
that allows for the generation of hypotheses about factors that may contribute to the onset
and/or expression of gender dysphoria among AYAs. Emerging hypotheses include the pos-
sibility of a potential new subcategory of gender dysphoria (referred to as rapid-onset gender
dysphoria) that has not yet been clinically validated and the possibility of social influences
and maladaptive coping mechanisms. Parent-child conflict may also explain some of the
findings. More research that includes data collection from AYAs, parents, clinicians and
third party informants is needed to further explore the roles of social influence, maladaptive
coping mechanisms, parental approaches, and family dynamics in the development and
duration of gender dysphoria in adolescents and young adults.
Introduction
In recent years, a number of parents have begun reporting in online discussion groups such as
4thwavenow in the US (https://4thwavenow.com) and Transgender Trend in the UK (https://
www.transgendertrend.com) that their adolescent and young adult (AYA) children, who have
had no histories of childhood gender identity issues, experienced a perceived sudden or rapid
Rapid-onset gender dysphoria in adolescents and young adults
PLOS ONE | https://doi.org/10.1371/journal.pone.0202330 August 16, 2018 2 / 44
risk of participant recognition through linkage of
details. As participants’ identifiers were not
collected it is not possible to contact participants
and ask for their consent to disclose at this time.
For any questions about restriction on data
sharing, please contact PPHS at the Icahn School
of Medicine at Mount Sinai (IRB@mssm.edu).
Funding: The author received no specific funding
for this work.
Competing interests: Lisa Littman, MD, MPH,
provides public health consulting on topics
unrelated to this research. She is a member of
several professional organizations including the
American College of Preventive Medicine (ACPM),
the American Public Health Association (APHA),
the Society for Adolescent Health and Medicine
(SAHM), the Society of Family Planning (SFP), the
International Academy of Sex Research (IASR),
and the World Professional Association for
Transgender Health (WPATH).
onset of gender dysphoria. Parents have described clusters of gender dysphoria in pre-existing
friend groups with multiple or even all members of a friend group becoming gender dysphoric
and transgender-identified in a pattern that seems statistically unlikely based on previous
research [1–8]. Parents describe a process of immersion in social media, such as “binge-watch-
ing” YouTube transition videos and excessive use of Tumblr, immediately preceding their
child becoming gender dysphoric [1–2,9]. These types of presentations have not been
described in the research literature for gender dysphoria [1–10] and raise the question of
whether social influences may be contributing to or even driving these occurrences of gender
dysphoria in some populations of adolescents and young adults. (Note: The terminology of
“natal sex”, including the terms “natal female” and “natal male”, will be used throughout this
article. Natal sex refers to an individual’s sex as it was observed and documented at the time of
birth. Some researchers also use the terminology “assigned at birth”.)
Background
Gender dysphoria in adolescents
Gender dysphoria (GD) is defined as an individual’s persistent discomfort with their biological
sex or assigned gender [11]. Two types of gender dysphoria studied include early-onset gender
dysphoria, where the symptoms of gender dysphoria begin in early childhood, and late-onset
gender dysphoria, where the symptoms begin after puberty [11]. Late-onset gender dysphoria
that occurs during adolescence is now called adolescent-onset gender dysphoria. The majority
of adolescents who present for care for gender dysphoria are individuals who experienced
early-onset gender dysphoria that persisted or worsened with puberty although an atypical
presentation has been described where adolescents who did not experience childhood symp-
toms present with new symptoms in adolescence [7,12]. Adolescent-onset of gender dysphoria
has only recently been reported in the literature for natal females [5,10,13–14]. In fact, prior to
2012, there were little to no research studies about adolescent females with gender dysphoria
first beginning in adolescence [10]. Thus, far more is known about adolescents with early-
onset gender dysphoria than adolescents with adolescent-onset gender dysphoria [6,15].
Although not all research studies on gender dysphoric adolescents exclude those with adoles-
cent-onset gender dysphoria [10], it is important to note that most of the studies on adoles-
cents, particularly those about gender dysphoria persistence and desistance rates and
outcomes for the use of puberty suppression, cross-sex hormones, and surgery only included
subjects whose gender dysphoria began in childhood and subjects with adolescent-onset gen-
der dysphoria would not have met inclusion criteria for these studies [16–24]. Therefore, most
of the research on adolescents with gender dysphoria to date is not generalizable to adolescents
experiencing adolescent-onset gender dysphoria [16–24] and the outcomes for individuals
with adolescent-onset gender dysphoria, including persistence and desistence rates and out-
comes for treatments, are currently unknown.
As recently as 2012, there were only two clinics (one in Canada and one in the Netherlands)
that had gathered enough data to provide empirical information about the main issues for gen-
der dysphoric adolescents [25]. Both institutions concluded that the management of adoles-
cent-onset gender dysphoria is more complicated than the management of early-onset gender
dysphoria and that individuals with adolescent-onset are more likely to have significant psy-
chopathology [25]. The presentation of gender dysphoria can occur in the context of severe
psychiatric disorders, developmental difficulties, or as part of large-scale identity issues and,
for these patients, medical transition might not be advisable [13]. The APA Task Force on the
Treatment of Gender Identity Disorder notes that adolescents with gender dysphoria “should
be screened carefully to detect the emergence of the desire for sex reassignment in the context
Rapid-onset gender dysphoria in adolescents and young adults
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of trauma as well as for any disorder (such as schizophrenia, mania, psychotic depression) that
may produce gender confusion. When present, such psychopathology must be addressed and
taken into account prior to assisting the adolescent’s decision as to whether or not to pursue
sex reassignment or actually assisting the adolescent with the gender transition.” [25].
Demographic and clinical changes for gender dysphoria
Although, by 2013, there was research documenting that a significant number of natal males
experienced gender dysphoria that began during or after puberty, there was little information
about this type of presentation for natal females [5]. Starting in the mid-2000s there has been a
substantial change in demographics of patients presenting for care with most notably an
increase in adolescent females and an inversion of the sex ratio from one favoring natal males
to one favoring natal females [26–28]. And now, some clinicians have noted that they are see-
ing increasingly in their clinic, the phenomenon of natal females expressing a post-puberty
rapid onset of gender dysphoria [14]. Some researchers have suggested that increased visibility
of transgender people in the media, availability of information online, with a partial reduction
of stigma may explain some of the increases in numbers of patients seeking care [27], but these
factors would not explain the reversal of the sex ratio, disproportionate increase in adolescent
natal females, and the new phenomenon of natal females experiencing gender dysphoria that
begins during or after puberty. If there were cultural changes that made it more acceptable for
natal females to seek transition [27], that would not explain why the reversal of the sex ratio
reported for adolescents has not been reported for older adult populations [26]. There are
many unanswered questions about potential causes for the recent demographic and clinical
changes for gender dysphoric individuals.
Social and peer influences
Parental reports (on social media) of friend clusters exhibiting signs of gender dysphoria [1–4]
and increased exposure to social media/internet preceding a child’s announcement of a trans-
gender identity [1–2,9] raise the possibility of social and peer influences. In developmental psy-
chology research, impacts of peers and other social influences on an individual’s development
are sometimes described using the terms peer contagion and social contagion, respectively. The
use of “contagion” in this context is distinct from the term’s use in the study of infectious dis-
ease, and furthermore its use as an established academic concept throughout this article is not
meant in any way to characterize the developmental process, outcome, or behavior as a disease
or disease-like state, or to convey any value judgement. Social contagion [29] is the spread of
affect or behaviors through a population. Peer contagion, in particular, is the process where an
individual and peer mutually influence each other in a way that promotes emotions and behav-
iors that can potentially have negative effects on their development [30]. Peer contagion has
been associated with depressive symptoms, disordered eating, aggression, bullying, and drug
use [30–31]. Internalizing symptoms such as depression can be spread via the mechanisms of
co-rumination, which entails the repetitive discussion of problems, excessive reassurance seek-
ing (ERS), and negative feedback [30,32–34]. Deviancy training, which was first described for
rule breaking, delinquency, and aggression, is the process whereby attitudes and behaviors asso-
ciated with problem behaviors are promoted with positive reinforcement by peers [35,36].
Peer contagion has been shown to be a factor in several aspects of eating disorders. There
are examples in the eating disorder and anorexia nervosa literature of how both internalizing
symptoms and behaviors have been shared and spread via peer influences [37–41] which may
have relevance to considerations of a rapid onset of gender dysphoria occurring in AYAs.
Friendship cliques can set the norms for preoccupation with one’s body, one’s body image,
Rapid-onset gender dysphoria in adolescents and young adults
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and techniques for weight loss, and can predict an individual’s body image concerns and eat-
ing behaviors [37–39]. Peer influence is intensified in inpatient and outpatient treatment set-
tings for patients with anorexia and counter-therapeutic subcultures that actively promote the
beliefs and behaviors of anorexia nervosa have been observed [39–41]. In these settings, there
is a group dynamic where the “best” anorexics (those who are thinnest, most resistant to gain-
ing weight, and who have experienced the most medical complications from their disease) are
admired, validated, and seen as authentic while the patients who want to recover from
anorexia and cooperate with medical treatment are maligned, ridiculed, and marginalized
[39–41]. Additionally, behaviors associated with deceiving parents and doctors about eating
and weight loss, referred to as the “anorexic tricks,” are shared by patients in a manner akin to
deviancy training [39–41]. Online environments provide ample opportunity for excessive reas-
surance seeking, co-rumination, positive and negative feedback, and deviancy training from
peers who subscribe to unhealthy, self-harming behaviors. The pro-eating disorder sites pro-
vide motivation for extreme weight loss (sometimes calling the motivational content “thin-
spiration”)[42–44]. Such sites promote validation of eating disorder as an identity, and offer
“tips and tricks” for weight loss and for deceiving parents and doctors so that individuals may
continue their weight-loss activities [42–44]. If similar mechanisms are at work in the context
of gender dysphoria, this greatly complicates the evaluation and treatment of impacted AYAs.
In the past decade, there has been an increase in visibility, social media, and user-generated
online content about transgender issues and transition [45], which may act as a double-edged
sword. On the one hand, an increase in visibility has given a voice to individuals who would
have been under-diagnosed and undertreated in the past [45]. On the other hand, it is plausible
that online content may encourage vulnerable individuals to believe that nonspecific symp-
toms and vague feelings should be interpreted as gender dysphoria stemming from a transgen-
der condition. Recently, leading international academic and clinical commentators have raised
the question about the role of social media and online content in the development of gender
dysphoria [46]. Concern has been raised that adolescents may come to believe that transition
is the only solution to their individual situations, that exposure to internet content that is
uncritically positive about transition may intensify these beliefs, and that those teens may pres-
sure doctors for immediate medical treatment [25]. There are many examples on popular sites
such as Reddit (www.reddit.com with subreddit ask/r/transgender) and Tumblr (www.tumblr.
com) where online advice promotes the idea that nonspecific symptoms should be considered
to be gender dysphoria, conveys an urgency to transition, and instructs individuals how to
deceive parents, doctors, and therapists to obtain hormones quickly [47]. Fig 1 includes exam-
ples of online advice from Reddit and Tumblr.
Purpose
Rapid presentations of adolescent-onset gender dysphoria occurring in clusters of pre-existing
friend groups are not consistent with current knowledge about gender dysphoria and have not
been described in the scientific literature to date [1–8]. The purpose of this descriptive, explor-
atory research is to (1) collect data about parents’ observations, experiences, and perspectives
about their AYA children showing signs of a rapid onset of gender dysphoria that began dur-
ing or after puberty, and (2) develop hypotheses about factors that may contribute to the onset
and/or expression of gender dysphoria among this demographic group.
Materials and methods
The Icahn School of Medicine at Mount Sinai, Program for the Protection of Human Subjects
provided approval of research for this project (HS#: 16–00744).
Rapid-onset gender dysphoria in adolescents and young adults
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Participants
During the recruitment period, 256 parents completed online surveys that met the study crite-
ria. The sample of parents included more women (91.7%) than men (8.3%) and participants
were predominantly between the ages of 45 and 60 (66.1%) (Table 1). Most respondents were
White (91.4%), non-Hispanic (99.2%), and lived in the United States (71.7%). Most respon-
dents had a Bachelor’s degree (37.8%) or graduate degree (33.1%). The adolescents and young
adults (AYAs) described by their parents were predominantly female sex at birth (82.8%) with
an average current age of 16.4 years (range, 11–27 years). See Table 2.
Procedure
A 90-question survey instrument with multiple choice, Likert-type, and open-ended questions
was created by the researcher. The survey was designed for parents (respondents) to complete
about their adolescent and young adult children. The survey was uploaded onto Survey Mon-
key (SurveyMonkey, Palo Alto, CA, USA) via an account that was HIPPA-enabled. IRB
approval for the study from the Icahn School of Medicine at Mount Sinai in New York, NY
was received. Recruitment information with a link to the survey was placed on three websites
where parents and professionals had been observed to describe what seemed to be a sudden or
rapid onset of gender dysphoria (4thwavenow, transgender trend, and youthtranscriticalpro-
fessionals), although the specific terminology “rapid onset gender dysphoria” did not appear
on these websites until the recruitment information using that term was first posted on the
sites. Website moderators and potential participants were encouraged to share the recruitment
information and link to the survey with any individuals or communities that they thought
might include eligible participants to expand the reach of the project through snowball sam-
pling techniques. The survey was active from June 29, 2016 to October 12, 2016 (3.5 months)
Fig 1. Example quotes of online advice from Reddit and Tumblr.
https://doi.org/10.1371/journal.pone.0202330.g001
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and took 30–60 minutes to complete. Participants completed the survey at a time and place of
their own choosing. Data were collected anonymously and stored securely with Survey
Monkey.
Participation in this study was voluntary and its purpose was clearly described in the
recruitment information. Electronic consent was obtained. Participants had the option to
withdraw consent at any time prior to submitting responses. Inclusion criteria were (1) com-
pletion of a survey with parental response that the child had a sudden or rapid onset of gender
dysphoria; and (2) parental indication that the child’s gender dysphoria began during or after
puberty. There was logic embedded in the survey that disqualified surveys that answered “no”
(or skipped the question) about whether the child had a sudden or rapid onset of gender dys-
phoria and 23 surveys were disqualified prior to completion (20 “no” answers and 3 skipped
Table 1. Demographic and other baseline characteristics of parent respondents.
Characteristics of Parent-respondents n %
Sex 254
Female 233 91.7
Male 21 8.3
Age (y) 254
18–29 3 1.2
30–44 74 29.1
45–60 168 66.1
>60 9 3.5
Race/Ethnicity�255
White 233 91.4
Other�� 22 8.6
Country of Residence 254
US 182 71.7
UK 39 15.4
Canada 17 6.7
Other 16 6.3
Education 254
Bachelor’s degree 96 37.8
Graduate degree 84 33.1
Some college or
Associates degree
63 24.8
HS grad or GED 10 3.9
<High School 1 0.4
Parent attitude on allowing gay and lesbian couples to marry legally 256
Favor 220 85.9
Oppose 19 7.4
Don’t know 17 6.6
Parent belief that transgender people deserve the same
rights and protections as others
255
Yes 225 88.2
No 8 3.1
Don’t know 20 7.8
Other 2 0.8
�may select more than one answer.
�� declining order includes: Other, Multiracial, Asian, Hispanic.
https://doi.org/10.1371/journal.pone.0202330.t001
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answers). After cleaning the data for the 274 completed surveys, 8 surveys were excluded for
not having a sudden or rapid onset of gender dysphoria and 10 surveys were excluded for not
having gender dysphoria that began during or after puberty, which left 256 completed surveys
for inclusion. As the survey was voluntary there was no refusal or dropout rate.
Recruitment sites
There were four sites known to post recruitment information about the research study. The
first three were posted due to direct communication with the moderators of the sites. The
fourth site posted recruitment information secondary to the snowball sampling technique. The
following descriptions provide details about these sites.
Table 2. Demographic and other baseline characteristics of AYAs.
Characteristics of AYAs n %
AYA sex at birth (natal sex) 256
Female 212 82.8
Male 44 17.2
AYA average current age (range of ages) 16.4 (11–27) 256
Academic diagnoses 253
Gifted 120 47.4
Learning Disability 11 4.3
Both 27 10.7
Neither 95 37.5
Natal female expressed sexual orientation
before announcement�
212
Asexual 18 8.5
Bisexual or Pansexual 78 36.8
Gay or Lesbian 58 27.4
Straight (Heterosexual) 75 35.4
Did not express 57 26.9
Natal male expressed sexual orientation
before announcement�
44
Asexual 4 9.1
Bisexual or Pansexual 5 11.4
Gay 5 11.4
Straight (Heterosexual) 25 56.8
Did not express 11 25.0
Gender dysphoria began 256
During puberty 125 48.8
After puberty 131 51.2
Along with a rapid onset of GD,
the AYA also:
256
Belonged to a friend group where one or multiple
friends became transgender-identified during
a similar timeframe
55 21.5
Had an increase in social media/internet use 51 19.9
Both of the above 116 45.3
Neither 13 5.1
Don’t know 21 8.2
�may select more than one answer.
https://doi.org/10.1371/journal.pone.0202330.t002
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4thwavenow
4thwavenow was created in 2015. The site, as seen in digitally archived screenshots from 2015
and 2016, stated that it is a “safe place for gender-skeptical parents and their allies”, offered
support for parents, and expressed concern about the rush to diagnose young people as trans-
gender and the rush to proceed to medical treatment for them [2,48]. By June 2016, the site
had expanded to include the writing of several parents, “formerly trans-identified people, and
people with professional expertise and experience with young people questioning their gender
identity” [9]. The perspective of this site might be described as cautious about medical and sur-
gical transition overall—specifically with a cautious or negative view of medical and surgical
interventions for children, adolescents, and young adults and an accepting view that mature
adults can make their own decisions about transition [2,9].
Transgendertrend
Transgendertrend was founded in November 2015. The digitally archived screenshots from
November 2015 and July 2016 “Who Are We?” section include the following description, “We
are an international group of parents based mainly in the UK, US and Canada, who are con-
cerned about the current trend to diagnose ‘gender non-conforming’ children as transgender.
We reject current conservative, reactionary, religious-fundamentalist views about sexuality.
We come from diverse backgrounds, some with expertise in child development and psychol-
ogy, some who were themselves extreme gender non-conforming children and adolescents,
some whose own children have self-diagnosed as ‘trans’ and some who know supportive trans
adults who are also questioning recent theories of ‘transgenderism’” [49]. In July of 2016, there
was additional text added, expressing concern about legislation regarding public bathrooms
and changing rooms [50].
Youth trans critical professionals
Youth Trans Critical Professionals was created in March 2016. The digitally archived screen-
shot from the April 2016 “About” section stated the following: “This website is a community of
professionals “thinking critically about the youth transgender movement. We are psycholo-
gists, social workers, doctors, medical ethicists, and academics. We tend to be left-leaning,
open-minded, and pro-gay rights. However, we are concerned about the current trend to
quickly diagnose and affirm young people as transgender, often setting them down a path
toward medical transition. Our concern is with medical transition for children and youth. We
feel that unnecessary surgeries and/or hormonal treatments which have not been proven safe
in the long-term represent significant risks for young people” [51].
Parents of transgender children
Parents of Transgender Children is a private Facebook group with more than 8,000 members
[52]. The current “About” section states that requests to join the group “will be denied if you
are not the parent (or immediate caregiver or family member) of a transgender, gender-fluid,
gender-questioning, agender, or other gender-nonconforming child (of any age); or if you are
uncooperative during screening” and that the “group is comprised of parents and parenting
figures, as well as a select group of advocates INVITED by the admin[istrative] staff to assist &
help us with understanding legal and other concerns” [52]. Although the parent discussions
and comments are not viewable to non-members [52], this group is perceived to be pro -gen-
der-affirming. The Parents of Transgender Children Facebook group is considered to be a site
to find parents who are supportive of their child’s gender identity [53], and it is listed as a
Rapid-onset gender dysphoria in adolescents and young adults
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resource in a gender affirming parenting guide [54] and by gender affirming organizations
[55–56].
Measures
Basic demographic and baseline characteristics
Basic demographic and baseline characteristic questions, including parental attitudes about
LGBT rights, were included. Parents were asked about their children’s mental health disorders
and neurodevelopmental disabilities that were diagnosed before their child’s onset of gender
dysphoria as well as during and after. The question, “Has your child been formally identified
as academically gifted, learning disabled, both, neither?” was used as a proxy to estimate rates
of academic giftedness and learning disabilities. Questions about trauma and non-suicidal self-
injury were also included as were questions about social difficulties described in a previous
research study about gender dysphoric adolescents [13].
DSM-5 diagnostic criteria for gender dysphoria in children
The DSM 5 criteria for gender dysphoria in children consist of eight indicators of gender dys-
phoria [57]. To meet criteria for diagnosis, a child must manifest at least six out of eight indica-
tors including the one designated A1, “A strong desire to be the other gender or an insistence
that one is the other gender (or some alternative gender different from one’s assigned gen-
der).” Three of the indicators (A1, A7, and A8) refer to desires or dislikes of the child. Five of
the indicators (A2-A6) are readily observable behaviors and preferences such as a strong pref-
erence or strong resistance to wearing certain kinds of clothing; a strong preference or strong
rejection of specific toys, games and activities; and a strong preference for playmates of the
other gender [57]. The eight indicators were simplified for language and parents were asked to
note which, if any, their child had exhibited prior to puberty. The requirement of six-month
duration of symptoms was not included.
DSM-5 diagnostic criteria for gender dysphoria in adolescents and adults
The DSM-5 criteria for gender dysphoria in adolescents and adults consist of six indicators of
gender dysphoria [57]. To meet criteria for diagnosis, an adolescent or adult must manifest at
least two of the six indicators. The six indicators were simplified for language, the first indica-
tor was adjusted for a parent to answer about their child, and parents were asked to note
which, if any, their child was expressing currently. The requirement of six-month duration of
symptoms was not included.
Exposure to friend groups and social media/internet content
Survey questions were developed to describe AYA friend groups, including number of friends
that became transgender-identified in a similar time period as the AYA, peer group dynamics
and behaviors, and exposure to specific types of social media/internet content and messages
that have been observed on sites popular with teens, such as Reddit and Tumblr.
Behaviors, outcomes, clinical interactions
Survey questions were developed to specifically quantify adolescent behaviors that had been
described by parents in online discussions and observed elsewhere. Participants were asked to
describe outcomes such as their child’s mental well-being and parent-child relationship since
becoming transgender-identified. Parents were also asked about experiences with clinicians
and their children’s disposition regarding steps taken for transition and duration of
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transgender-identification both for children who were still transgender-identified and for chil-
dren who were no longer transgender-identified.
Coping with strong or negative emotions
Two questions about the AYAs’ ability to cope with negative and strong emotions were
included. One question was “How does your child handle strong emotions? (please select the
best answer).” Offered answers were “My child is overwhelmed by strong emotions and goes
to great lengths to avoid feeling them,” “My child is overwhelmed by strong emotions and tries
to avoid feeling them,” “My child neither avoids not seeks out strong emotions,” “My child
tries to seek out situations in order to feel strong emotions,” “My child goes to great lengths to
seek out situations in order to feel strong emotions,” “None of the above,” “I don’t know.” The
other question was “How would you rate your child’s ability to deal with their negative emo-
tions and channel them into something productive?” An example was given regarding dealing
with a low test grade by studying harder for the next test (excellent) or by ignoring it, throwing
a tantrum, blaming the teacher or distracting themselves with computer games, alcohol, drugs,
etc. (extremely poor). Offered answers were: excellent, good, fair, poor, extremely poor, and I
don’t know.
Data analysis
Statistical analyses of quantitative data were performed using Excel and custom shell scripts
(Unix). Quantitative findings are presented as frequencies, percentages, ranges, means and/or
medians. ANOVAs, chi-squared, and t-tests comparisons were used where appropriate using
publicly available calculators and p<0.05 was considered significant. Qualitative data were
obtained from open text answers to questions that allowed participants to provide additional
information or comments. The types of comments and descriptions were categorized, tallied,
and reported numerically. A grounded theory approach was selected as the analytic strategy of
choice for handling the qualitative responses because it allowed the researcher to assemble the
data in accordance with the salient points the respondents were making without forcing the
data into a preconceived theoretical framework of the researcher’s own choosing [58]. Illustra-
tive respondent quotes and summaries from the qualitative data are used to illustrate the quan-
titative results and to provide relevant examples. Two questions were targeted for full
qualitative analysis of themes (one question on friend group behaviors and one on clinician
interactions). For these questions, a second reviewer with expertise in qualitative methods was
engaged (MM). Both the author (LL) and reviewer (MM) independently analyzed the content
of the open text answers and identified major themes. Discrepancies were resolved with collab-
orative discussion and themes were explored and refined until agreement was reached for the
final lists of themes. Representative quotes for each theme were selected by LL, reviewed by
MM, and agreement was reached.
Results
Baseline characteristics
Baseline characteristics (Table 1) included that the vast majority of parents favored gay and les-
bian couples’ right to legally marry (85.9%) and believed that transgender individuals deserve
the same rights and protections as other individuals in their country (88.2%). Along with the
sudden or rapid onset of gender dysphoria, the AYAs belonged to a friend group where one or
multiple friends became gender dysphoric and came out as transgender during a similar time
as they did (21.5%), exhibited an increase in their social media/internet use (19.9%), both
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(45.3%), neither (5.1%), and don’t know (8.2%) (Table 2). For comparisons, the first three cate-
gories will be combined and called “social influence” (86.7%) and the last two combined as “no
social influence” (13.3%). Nearly half (47.4%) of the AYAs had been formally diagnosed as aca-
demically gifted, 4.3% had a learning disability, 10.7% were both gifted and learning disabled,
and 37.5% were neither. Sexual orientation as expressed by the AYA prior to transgender-
identification is listed separately for natal females and for natal males (Table 2). Overall, 41%
of the AYAs expressed a non-heterosexual sexual orientation prior to disclosing a transgen-
der-identification.
It is important to note that none of the AYAs described in this study would have met diag-
nostic criteria for gender dysphoria in childhood (Table 3). In fact, the vast majority (80.4%)
had zero indicators from the DSM-5 diagnostic criteria for childhood gender dysphoria with
12.2% possessing one indicator, 3.5% with two indicators, and 2.4% with three indicators.
Breaking down these results, for readily observable indicators (A2-6), 83.5% of AYAs had zero
indicators, 10.2% had one indicator, 3.9% had two indicators, and 1.2% had three indicators.
For the desire/dislike indicators (A1, A7, A8), which a parent would have knowledge of if the
child expressed them verbally, but might be unaware if a child did not, 95.7% had zero indica-
tors and 3.5% had one indicator. Parents responded to the question about which, if any, of the
indicators of the DSM criteria for adolescent and adult gender dysphoria their child was
Table 3. DSM 5 Indicators for gender dysphoria.
Characteristics n %
AYAs who would have met diagnostic criteria for
gender dysphoria in childhood
0 0
Number of DSM 5 indicators for
gender dysphoria in children exhibited prior to puberty
255
Zero indicators 205 80.4
One indicator 31 12.2
Two indicators 9 3.5
Three indicators 6 2.4
Four indicators 3 1.2
Desire/Dislike Indicators (A1, A7, or A8) 255
Zero indicators 244 95.7
One indicators 9 3.5
Two indicators 0 0
Three indicators 1 0.4
Readily observable indicators (A2-A6) 254
Zero indicators 212 83.5
One indicator 26 10.2
Two indicators 10 3.9
Three indicators 3 1.2
Four indicators 3 1.2
Average number of DSM 5 indicators for adolescent and adult
gender dysphoria that the AYA is experiencing currently (range)
3.5 (range 0–6) 247
AYAs currently experiencing two or more indicators of gender
dysphoria for adolescents and adults
250
Yes 208 83.2
No 40 16.0
Don’t know 2 0.8
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experiencing currently. The average number of positive current indicators was 3.5 (range 0–6)
and 83.2% of the AYA sample was currently experiencing two or more indicators. Thus, while
the focal AYAs did not experience childhood gender dysphoria, the majority of those who
were the focus of this study were indeed gender dysphoric at the time of the survey
completion.
The AYAs who were the focus of this study had many comorbidities and vulnerabilities pre-
dating the onset of their gender dysphoria, including psychiatric disorders, neurodevelopmen-
tal disabilities, trauma, non-suicidal self-injury (NSSI), and difficulties coping with strong or
negative emotions (Table 4). The majority (62.5%) of AYAs had one or more diagnoses of a
psychiatric disorder or neurodevelopmental disability preceding the onset of gender dysphoria
(range of the number of pre-existing diagnoses 0–7). Many (48.4%) had experienced a trau-
matic or stressful event prior to the onset of their gender dysphoria. Open text descriptions of
trauma were categorized as “family” (including parental divorce, death of a parent, mental dis-
order in a sibling or parent), “sex or gender related” (such as rape, attempted rape, sexual
harassment, abusive dating relationship, break-up), “social” (such as bullying, social isolation),
“moving” (family relocation or change of schools); “psychiatric” (such as psychiatric hospitali-
zation), and medical (such as serious illness or medical hospitalization). Almost half (45.0%) of
AYAs were engaging in non-suicidal self-injury (NSSI) behavior before the onset of gender
dysphoria. Coping styles for these AYAs included having a poor or extremely poor ability to
handle negative emotions productively (58.0%) and being overwhelmed by strong emotions
and trying to avoid (or go to great lengths to avoid) experiencing them (61.4%) (Table 4). The
majority of respondents (69.4%) answered that their child had social anxiety during adoles-
cence; 44.3% that their child had difficulty interacting with their peers, and 43.1% that their
child had a history of being isolated (not associating with their peers outside of school
activities).
Announcing a transgender-identification
At the time the AYA announced they were transgender-identified (“came out”), most were liv-
ing at home with one or both parents (88.3%) and a small number were living at college
(6.2%). The average age of announcement of a transgender-identification was 15.2 years of age
(range 10–21) (Table 5). Most of the parents (80.9%) answered affirmatively that their child’s
announcement of being transgender came “out of the blue without significant prior evidence
of gender dysphoria.” Respondents were asked to pinpoint a time when their child seemed not
at all gender dysphoric and to estimate the length of time between that point and their child’s
announcement of a transgender-identity. Almost a third of respondents (32.4%) noted that
their child did not seem gender dysphoric when they made their announcement and 26.0%
said the length of time from not seeming gender dysphoric to announcing a transgender iden-
tity was between less than a week to three months. The most striking examples of “not seeming
at all gender dysphoric” prior to making the announcement included a daughter who loved
summers and seemed to love how she looked in a bikini, another daughter who happily wore
bikinis and makeup, and another daughter who previously said, “I love my body!”
The majority of respondents (69.2%) believed that their child was using language that they
found online when they “came out.” A total of 130 participants provided optional open text
responses to this question, and responses fell into the following categories: why they thought
the child was using language they found online (51); description of what the child said but
didn’t provide a reason that they suspected the child was using language they found online
(61); something else about the conversation (8) or the child (7) and don’t know (3). Of the 51
responses describing reasons why respondents thought their child was reproducing language
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Table 4. AYA baseline comorbidities and vulnerabilities predating the onset of gender dysphoria.
Characteristics n %
Mental disorder or neurodevelopmental disability
diagnosed prior to the onset of gender dysphoria�
251
Anxiety 117 46.6
Depression 99 39.4
Attention Deficit Hyperactivity Disorder (ADHD) 29 11.6
Obsessive Compulsive Disorder (OCD) 21 8.4
Autism Spectrum Disorder (ASD) 20 8.0
Eating Disorder 12 4.8
Bipolar Disorder 8 3.2
Psychosis 6 2.4
None of above 94 37.5
(Other) Borderline 3 1.2
(Other) Oppositional Defiant Disorder 2 0.8
Traumatic or stressful experience prior to the onset of gender dysphoria 252
Yes 122 48.4
No 91 36.1
Don’t know 38 15.1
Other 1 0.4
Types of trauma�113
Family 50 44.2
Sex/Gender related 34 30.1
Social 23 20.4
Moving 20 17.7
Psychiatric 9 8.0
Medical 7 6.2
Non-suicidal self-injury (NSSI) before the onset of gender dysphoria 180
81 45.0
Ability to handle negative emotions productively 255
Excellent/Good 34 13.3
Fair 70 27.5
Poor/Extremely Poor 148 58.0
Don’t know 3 1.2
Coping style for dealing with strong emotions 254
Overwhelmed by strong emotions and tries to /goes to great
lengths to avoid feeling them
156 61.4
Neither avoids nor seeks out strong emotions 29 11.4
Tries to/goes to great lengths to seeks out strong emotions 33 13.0
Don’t know 25 9.8
None of the above 11 4.3
Social vulnerabilities 255
During adolescence child had social anxiety 177 69.4
Child had difficulty interacting with their peers 113 44.3
History of being isolated (not interacting with peers outside
of school activities)
110 43.1
Child felt excluded by peers throughout most of grade school 93 36.5
Child had persistent experiences of being bullied before the
onset of gender dysphoria
74 29.0
�may select more than one answer.
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Table 5. Announcing a transgender-identification.
Characteristics n %
Age of AYA when the AYA announced a
transgender-identification (range)
15.2 average (10–21) 255
Living arrangement at announcement 256
Living at home with one or both parents 226 88.3
Living at college or university 16 6.2
Other 14 5.5
AYA’s announcement came from “out of the blue, without
significant prior evidence of gender dysphoria”
256
Yes 207 80.9
No 33 12.9
Other 16 6.2
If a time was pinpointed when the child seemed
not at all gender dysphoric, how long between that time and
the child’s announcement of a transgender-identity?
250
Did not seem at all gender dysphoric when they
announced and transgender-identity
81 32.4
Less than a week to 3 months 65 26.0
4–6 months 31 12.4
7–9 months 10 4.0
10–12 months 29 11.6
More than 12 months 20 8.0
Don’t know 14 5.6
Parent suspects that when the child first announced a
transgender-identity, that the child used language
that they found online
253
Yes 175 69.2
No 53 20.9
N/A 25 9.9
Parent thinks their child is correct in their child’s belief of being
transgender
255
Yes 6 2.4
No 195 76.5
Don’t know 38 14.9
Other 16 6.3
How soon after the announcement did the AYA ask for
transition?
255
At the same time 86 33.7
Between less than one week to one month 33 12.9
2–5 months after announcement 26 10.2
6 or more months after announcement 19 7.5
Other 16 6.3
N/A 75 29.4
Intention and request for transition�189
AYA told the parent that they want cross-sex hormones 127 67.2
AYA told the parent that they want to go to a gender
therapist/gender clinic
111 58.7
AYA told the parent that they want surgery 101 53.4
AYA brought up the issue of suicides in transgender teens as
a reason that their parent should agree to treatment
59 31.2
(Continued)
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they found online, the top two reasons were that it didn’t sound like their child’s voice (19
respondents) and that the parent later looked online and recognized the same words and
phrases that their child used when they announced a transgender identity (14 respondents).
The observation that it didn’t sound like their child’s voice was also expressed as “sounding
scripted,” like their child was “reading from a script,” “wooden,” “like a form letter,” and that it
didn’t sound like their child’s words. Parents described finding the words their child said to
them “verbatim,” “word for word,” “practically copy and paste,” and “identical” in online and
other sources. The following quotes capture these top two observations. One parent said, “It
seemed different from the way she usually talked—I remember thinking it was like hearing
someone who had memorized a lot of definitions for a vocabulary test.” Another respondent
said, “The email [my child sent to me] read like all of the narratives posted online almost word
for word.”
The following case summaries were selected to illustrate peer, trauma, and psychiatric con-
texts that might indicate more complicated clinical pictures.
• A 12-year-old natal female was bullied specifically for going through early puberty and the
responding parent wrote “as a result she said she felt fat and hated her breasts.” She learned
online that hating your breasts is a sign of being transgender. She edited her diary (by cross-
ing out existing text and writing in new text) to make it appear that she has always felt that
she is transgender.
• A 14-year-old natal female and three of her natal female friends were taking group lessons
together with a very popular coach. The coach came out as transgender, and, within one
year, all four students announced they were also transgender.
• A natal female was traumatized by a rape when she was 16 years of age. Before the rape, she
was described as a happy girl; after the rape, she became withdrawn and fearful. Several
months after the rape, she announced that she was transgender and told her parents that she
needed to transition.
• A 21-year-old natal male who had been academically successful at a prestigious university
seemed depressed for about six months. Since concluding that he was transgender, he went
on to have a marked decline in his social functioning and has become increasingly angry and
Table 5. (Continued)
Characteristics n %
AYA has very high expectation that transitioning
will solve their problems in social, academic,
occupational, or mental health areas
256
Yes 143 55.9
No 13 5.1
Don’t know 100 39.1
AYA was willing to work on basic mental health before
seeking gender treatments
253
Yes 111 43.9
No 71 28.1
Don’t know 30 11.9
N/A 41 16.2
�may select more than one answer.
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hostile to his family. He refuses to move out or look for a job. His entire family, including
several members who are very supportive of the transgender community, believe that he is
“suffering from a mental disorder which has nothing to do with gender.”
• A 14-year-old natal female and three of her natal female friends are part of a larger friend
group that spends much of their time talking about gender and sexuality. The three natal
female friends all announced they were trans boys and chose similar masculine names. After
spending time with these three friends, the 14-year-old natal female announced that she was
also a trans boy.
The majority (76.5%) of the surveyed parents felt that their child was incorrect in their belief
of being transgender (Table 5). More than a third (33.7%) of the AYAs asked for medical and/
or surgical transition at the same time that they announced they were transgender-identified.
Two thirds (67.2%) of the AYAs told their parent that they wanted to take cross-sex hormones;
58.7% that they wanted to see a gender therapist/gender clinic; and 53.4% that they wanted sur-
gery for transition. Almost a third (31.2%) of AYAs brought up the issue of suicides in transgen-
der teens as a reason that their parent should agree to treatment. More than half of the AYAs
(55.9%) had very high expectations that transitioning would solve their problems in social, aca-
demic, occupational or mental health areas. While 43.9% of AYAs were willing to work on basic
mental health before seeking gender treatments, a sizable minority (28.1%) were not willing to
work on their basic mental health before seeking gender treatment. At least two parents relayed
that their child discontinued psychiatric care and medications for pre-existing mental health
conditions once they identified as transgender. One parent, in response to the question about if
their child had very high expectations that transitioning would solve their problems elaborated,
“Very much so. [She] discontinued anti-depressant quickly, stopped seeing psychiatrist, began
seeing gender therapist, stopped healthy eating. [She] stated ‘none of it’ (minding what she ate
and taking her Rx) ‘mattered anymore.’ This was her cure, in her opinion.”
Friend-group exposure
The adolescent and young adult children were, on average, 14.4 years old when their first
friend became transgender-identified (Table 6). Within friendship groups, the average number
of individuals who became transgender-identified was 3.5 per group. In 36.8% of the friend
groups described, the majority of individuals in the group became transgender-identified. The
order that the focal AYA “came out” compared to the rest of their friendship group was calcu-
lated from the 119 participants who provided the number of friends coming out both before
and after their child and 74.8% of the AYAs were first, second or third of their group. Parents
described intense group dynamics where friend groups praised and supported people who
were transgender-identified and ridiculed and maligned non-transgender people. Where pop-
ularity status and activities were known, 60.7% of the AYAs experienced an increased popular-
ity within their friend group when they announced a transgender-identification and 60.0% of
the friend groups were known to mock people who were not transgender or LGBTIA (lesbian,
gay, bisexual, transgender, intersex, or asexual).
For the question about popularity changes when the child came out as having a transgen-
der-identification, 79 participants provided optional open text responses which were catego-
rized as: descriptions of the responses the child received (39); descriptions of the friends (14);
description that the child did not “come out” to friends (8); not sure (9); speculation on how
the child felt from the response (4), other (5). Of the 39 descriptions of responses, 19 of these
responses referred to positive benefits the child received after coming out including positive
attention, compliments, increased status, increased popularity, increased numbers of online
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followers, and improved protection from ongoing bullying. The following are quotes from
parents about the perceived benefits of transgender-identification afforded to their child. One
respondent said, “Great increase in popularity among the student body at large. Being trans is
a gold star in the eyes of other teens.” Another respondent explained, “not so much ‘popularity’
increasing as ‘status’. . .also she became untouchable in terms of bullying in school as teachers
who ignored homophobic bullying . . .are now all at pains to be hot on the heels of any trans
bullying.” Seven respondents described a mixed response where the child’s popularity
increased with some friends and decreased with others. Seven respondents described a neutral
response such as “All of the friends seemed extremely accepting.” Two described a temporary
increase in their child’s popularity: “There was an immediate rush of support when he came
out. Those same friends have dwindled to nothing as he rarely speaks to any of them now.”
Another described the loss of friends. And two parents described that “coming out” prevented
the loss of friends explained by one respondent as “to not be trans one would not have been
included in his group.”
Table 6. Friend group exposure.
Characteristics n %
The AYA has been part of a friend group where
one or more friends has come out as transgender
around a similar timeframe as they did
254
Yes 176 69.3
No 47 18.5
Don’t know 31 12.2
Age of AYA when their first friend became
transgender-identified (range)
14.4 average (11–21) 174
Number of friends from the friendship group who
became gender dysphoric average (range)
3.5 average (2–10) 138
Where numbers known, friend groups where
the MAJORITY of the friends in the friendship group
became transgender-identified
125
Yes 46 36.8
No 79 63.2
Order of the AYAs “coming out” compared to the others
in the friendship group
119
First in the friendship group 4 3.4
Second in the friendship group 52 43.7
Third in the friendship group 33 27.7
Fourth in the friendship group 18 15.1
Fifth in the friendship group 5 4.2
Sixth or Seventh in the friendship
group
6 5.0
Where popularity status known, change in popularity
within friend group when AYA announced their
transgender-identification
178
Increased popularity 108 60.7
Decreased popularity 11 6.2
Unchanged popularity 59 33.1
Where friend group activities known, friend group
known to mock people who are not transgender/LGBT
145
Yes 87 60.0
No 58 40.0
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Several AYAs expressed significant concern about the potential repercussions from their
friend group when they concluded that they were not transgender after all. There were two
unrelated cases with similar trajectories where the AYAs spent some significant time in a dif-
ferent setting, away from their usual friend group, without access to the internet. Parents
described that these AYAs made new friendships, became romantically involved with another
person, and during their time away concluded that they were not transgender. In both cases,
the adolescents, rather than face their school friends, asked to move and transfer to different
high schools. One parent said that their child, “. . .couldn’t face the stigma of going back to
school and being branded as a fake or phony. . . . Or worse, a traitor or some kind of
betrayer. . .[and] asked us if we could move.” In the other case, the parent relayed that their
child thought none of the original friends would understand and expressed a strong desire to
“. . .get out of the culture that ‘if you are cis, then you are bad or oppressive or clueless.’” Both
families were able to relocate and both respondents reported that their teens have thrived in
their new environments and new schools. One respondent described that their child expressed
relief that medical transition was never started and felt there would have been pressure to
move forward had the family not moved away from the peer group.
Qualitative analysis
The open-ended responses from the question about whether the AYAs and friends mocked,
teased, or made fun of individuals who weren’t transgender or LGBTIA was selected for addi-
tional qualitative analysis. Seven major themes were identified from the comments provided
by participants and are described, with representative supporting quotes.
Theme: Groups targeted. The groups targeted for mocking by the friend groups are often
heterosexual (straight) people and non-transgender people (called “cis” or “cisgender”). Some-
times animosity was also directed towards males, white people, gay and lesbian (non-transgen-
der) people, aromantic and asexual people, and “terfs”. One participant explained, “They are
constantly putting down straight, white people for being privileged, dumb and boring.”
Another participant elaborated, “In general, cis-gendered people are considered evil and
unsupportive, regardless of their actual views on the topic. To be heterosexual, comfortable
with the gender you were assigned at birth, and non-minority places you in the ‘most evil’ of
categories with this group of friends. Statement of opinions by the evil cis-gendered population
are consider phobic and discriminatory and are generally discounted as unenlightened.”
Theme: Individuals targeted. In addition to targeting specific groups of people for mock-
ing, the AYAs and their friend groups also directed mocking towards individuals in the AYAs’
lives such as parents, grandparents, siblings, peers, allies, and teachers. The following quotes
describe individuals targeted. One participant said, “They call kids who are not LGBT dumb
and cis. And the mocking has been aimed at my transgender-identified child’s [sibling].”
Another parent said, “They definitely made fun of parents and teachers who did not agree
with them.” And a third participant said, “. . .they were asked to leave [a school-based LGBT
club] because they were not queer enough [as straight and bisexual allies]. [One of them] was
[then] bullied, harassed and denounced online.”
Theme: Behaviors occurred both in person and in online settings. Parents observed the
behaviors both in-person and in online settings, and specifically mentioned seeing posts and
conversations on Tumblr, Twitter, Facebook, and Instagram. On participant said, “They speak
with derision about how cis-gendered people do not understand them and are so close-
minded.” Another participant said, “I hear them disparaging heterosexuality, marriage and
nuclear families.” Another participant said, “On my daughter’s Tumblr blog, she has liked or
favorited or re-posted disparaging comments about those who aren’t transgender or seem to
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misunderstand the transgender identity.” And another parent reported, “Her real life friends
don’t [mock non-LGBT people] but online they are always swapping jokes and comments
about cisgender and about transphobia.”
Theme: Examples of behaviors. Participants gave many examples of the observed behav-
iors that were mocking towards non-transgender people and non-LGB people. One partici-
pant said, “My daughter called me a ‘breeder’ and says things in a mocking ‘straight person
voice’. Her friends egg her on when she does this.” Another parent offered, “If they aren’t
mocking ‘cis’ people, they are playing pronoun police and mocking people who can’t get the
pronouns correct.” Another participant said, “New vocabulary includes ‘cis-stupid’ and ‘cis-
stupidity.’” And a fourth participant described, “They assume anyone that is critical about
being transgender (even just asking questions) is either ignorant or filled with hate.”
Theme: Emphasizing victimhood. Participants described that their children and friend
group seemed to focus on feeling as though they were victims. One participant described,
“They seem to wear any problems they may have, real or perceived like badges of honor. . .I
feel like they want to believe they are oppressed & have really ’been through life’, when they
have little life experience.” Another participant said, “. . .there is a lot of feeling like a victim
[and being] part of a victimized club.” Another parent said “But all talk is very ’victim’ cen-
tered”. And finally, another said, “They passionately decry ‘Straight Privilege’ and ‘White Male
Privilege’—while emphasizing their own ‘Victimhood.’”
Theme: Consequences of behaviors. A few participants describe that because of their
child’s behavior, there were consequences, including making it difficult for one child to return
to her school and the following description from another parent, “Most relatives have blocked
her on [social media] over constant jokes regarding cis and straight people.”
Theme: Fueling the behaviors. In some cases, parents describe a synergistic effect of kids
encouraging other kids to persist in the behavior as was described in a previous quote, “Her
friends egg her on when she does this” as well as the following, “Lots of discussion revolving
around how their teachers ‘discriminate’ or are ‘mean’ to them based on their declared
LGBTIA identity, and they get each other riled up convincing each other of their persecution
by these perceived wrongs . . . privately they mock our intolerance, and in person act upon
these false beliefs by treating us as people out to get them. . .”
Internet/social media exposure
In the time period just before announcing that they were transgender, 63.5% of AYAs exhib-
ited an increase in their internet/social media (Table 7). To assess AYA exposure to existing
online content, parents were asked what kind of advice their child received from someone/
people online. AYAs had received online advice including how to tell if they were transgender
(54.2%); the reasons that they should transition right away (34.7%); that if their parents did
not agree for them to take hormones that the parents were “abusive” and “transphobic”
(34.3%); that if they waited to transition they would regret it (29.1%); what to say and what not
to say to a doctor or therapist in order to convince them to provide hormones (22.3%); that if
their parents were reluctant to take them for hormones that they should use the “suicide narra-
tive” (telling the parents that there is a high rate of suicide in transgender teens) to convince
them (20.7%); and that it is acceptable to lie or withhold information about one’s medical or
psychological history from a doctor or therapist in order to get hormones/get hormones faster
(17.5%). Two respondents, in answers to other questions, described that their children later
told them what they learned from online discussion lists and sites. One parent reported, “He
has told us recently that he was on a bunch of discussion lists and learned tips there. Places
where teens and other trans people swap info. Like to use [certain, specific] words [with] the
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therapist when describing your GD, because [they are] code for potentially suicidal and will
get you a diagnosis and Rx for hormones.” Another parent disclosed, “The threat of suicide
was huge leverage. What do you say to that? It’s hard to have a steady hand and say no to medi-
cal transition when the other option is dead kid. She learned things to say that would push our
buttons and get what she wanted and she has told us now that she learned that from trans dis-
cussion sites.”
Parents identified the sources they thought were most influential for their child becoming
gender dysphoric. The most frequently answered influences were: YouTube transition videos
(63.6%); Tumblr (61.7%); a group of friends they know in person (44.5%); a community/group
of people that they met online (42.9%); a person they know in-person (not online) 41.7%. In
contrast to the majority of responses, two participants commented that they didn’t think the
Table 7. Internet/Social media exposures.
n %
AYAs internet/social media use just prior to announcement 255
Increased social media/internet use 162 63.5
Decreased social media/internet use 3 1.2
Unchanged social media/internet use 49 19.2
Don’t know 41 16.1
AYA exposure to internet content/advice�251
How to tell if they are transgender 136 54.2
The reasons that they should transition right away 87 34.7
That if their parents did not agree to take them for
hormones, that the parents are “abusive” and
“transphobic”
86 34.3
That if they waited to transition they would regret it 73 29.1
That if they didn’t transition immediately they would
never be happy
72 28.7
How to order physical items (binders, packers, etc)
without parents finding out
67 26.7
What to say and what NOT to say to a doctor or
therapist in order to convince them to provide
hormones
56 22.3
That if their parents are reluctant to take them
for hormones, that they should use the “suicide
narrative” to convince them (telling the parents that
there is a high rate of suicide in transgender teens.)
52 20.7
Medical advice about the risks and benefits of hormones 55 21.9
Medical advice about the risks and benefits of surgery 47 18.7
That it is acceptable to lie to or withhold information
about one’s medical or psychological history
from a doctor or therapist in order to get hormones/
get hormones faster
44 17.5
How to hide physical items from parents 40 15.9
How to hide or make excuses for physical changes 26 10.4
How to get money from others online in order to pay for
medications, etc
25 10.0
How to get hormones from online sources 24 9.6
How to hide hormones from parents 21 8.4
I don’t know if my child received online advice about these topics 127 50.6
�may select more than one answer.
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sources influenced their child to become gender dysphoric, rather they gave their child a name
for their feelings or gave the child confidence to come out. The following quotes illustrate the
dominant quantitative findings. One parent wrote, “We believe the biggest influence was the
online pro-transition blogs and youtube videos. We feel she was highly influenced by the ‘if
you are even questioning your gender-you are probably transgender’ philosophy. . .In the ‘real
world’ her friends, other trans peers, and newfound popularity were additional areas of rein-
forcement.” Another respondent described the online influence as part of a different question,
“I believe my child experienced what many kids experience on the cusp of puberty—uncom-
fortableness!—but there was an online world at the ready to tell her that those very normal
feelings meant she’s in the wrong body.”
Mental well-being, mental health, and behaviors
The trajectories of the AYAs were not consistent with the narrative of discovering one’s
authentic self and then thriving. Specifically, parents reported that, after “coming out,” their
children exhibited a worsening of their mental well-being. Additionally, parents noted worsen-
ing of the parent-child relationship and observed that their children had narrowed their inter-
ests (Table 8). Although small numbers of AYAs had improvement in mental well-being
(12.6%), parent-child relationship (7.4%), grades/academic performance (6.4%), and had
broadened their interests and hobbies (5.1%); the most common outcomes were worsened
mental well-being (47.2%); worsened parent child relationship (57.3%); unchanged or mixed
grades/academic performance (59.1%); and a narrowed range of interests and hobbies
Table 8. Outcomes and behaviors.
Characteristics n %
AYA mental well-being since
announcement
254
Worse 120 47.2
Better 32 12.6
Unchanged or mixed 101 39.8
Don’t know 1 0.4
Parent-child relationship since
announcement
253
Worse 145 57.3
Better 18 7.4
Unchanged or mixed 89 35.2
Don’t know 1 0.4
Grades/academic performance 220
Worse 76 34.5
Better 14 6.4
Unchanged/mixed 130 59.1
Range of interests and hobbies 255
Much broader 2 0.8
Somewhat broader 11 4.3
Unchanged 93 36.5
Somewhat narrower 64 25.1
Much narrower 56 22.0
There are very few topics outside of transgender
issues that my child is interested in
28 11.0
Don/t know 1 0.4
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(58.1%). One parent describing her child’s trajectory offered, “After announcing she was trans-
gender, my daughter’s depression increased significantly. She became more withdrawn. She
stopped participating in activities which she previously enjoyed, stopped participating in fam-
ily activities, and significantly decreased her interaction with friends. Her symptoms became
so severe that she was placed on medication by her physician.” Table 9 describes cumulative
rates of mental illness and neurodevelopmental disability at the time of survey.
A total of 63.8% of the parents have been called “transphobic” or “bigoted” by their children
for one or more reasons, the most common being for: disagreeing with the child about the
child’s self-assessment of being transgender (51.2%); recommending that the child take more
time to figure out if their feelings of gender dysphoria persist or go away (44.6%); expressing
concerns for the child’s future if they take hormones and/or have surgery (40.4%); calling their
child by the pronouns they used to use (37.9%); telling the child they thought that hormones
or surgery would not help them (37.5%); recommending that their child work on other mental
health issues first to determine if they are the cause of the dysphoria (33.3%); calling the child
by their birth name (33.3%); or recommending a comprehensive mental health evaluation
before starting hormones and/or surgery (20.8%) (Table 10). There were eight cases of
estrangement. Estrangement was child-initiated in six cases where the child ran away, moved
out, or otherwise refused contact with parent. There were two cases where the estrangement
was initiated by the parent because the AYA’s outbursts were affecting younger siblings or
there was a threat of violence made by the AYA to the parent.
AYAs are reported to have exhibited one or more of the following behaviors: expressed dis-
trust of information about gender dysphoria and transgenderism coming from mainstream
doctors and psychologists (51.8%); tried to isolate themselves from their family (49.4%);
expressed that they only trust information about gender dysphoria and transgenderism that
comes from transgender websites and/or transgender people and sources (46.6%); lost interest
in activities where participants aren’t predominantly transgender or LGBTIA (32.3%); stopped
spending time with friends who were not transgender (25.1%); expressed distrust of people
who were not transgender (22.7%) (Table 10). Many AYAs have also: withdrawn from their
family (45.0%); told other people or posted on social media that their parent is “transphobic,”
“abusive,” or “toxic” because the parent does not agree with child’s self-assessment of being
transgender (43.0%); refused to speak to their parent (28.5%), defended the practice of lying to
or withholding information from therapists or doctors in order to obtain hormones for transi-
tion more quickly (16.5%); tried to run away (6.8%). The behaviors and outcomes listed above
Table 9. AYA Cumulative mental disorder and neurodevelopmental disability diagnoses.
Characteristics n %
Mental disorder or neurodevelopmental disability 243
Anxiety 154 63.4
Depression 143 58.8
Attention Deficit Hyperactivity Disorder (ADHD) 36 14.8
Obsessive Compulsive Disorder (OCD) 30 12.3
Autism Spectrum Disorder (ASD) 30 12.3
Eating Disorder 17 7.0
Bipolar Disorder 17 7.0
Psychosis 8 3.3
None of above 52 21.4
(Other) Borderline 7 2.9
(Other) Oppositional Defiant Disorder 2 0.8
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Table 10. Additional behaviors.
n %
Parents have been called “transphobic” or
“bigoted” by their child for the following reasons�
240
Disagreeing with their child about the child’s assessment of being transgender 123 51.2
Recommending that their child take more time to figure out if their feelings of
gender dysphoria persist or go away
107 44.6
Expressing concerns for their child’s future if the child were to take hormones
and/or have surgery
97 40.4
Referring to their child by the pronouns that they used to use before announcement 91 37.9
Telling their child that they thought hormones/surgery would not help them 90 37.5
Calling their child by the child’s birth name 80 33.3
Recommending that their child work on other mental health issues first
to determine if they are the cause of their dysphoria
80 33.3
Recommending therapy for basic mental health issues (not related to gender) 74 30.8
Recommending a comprehensive evaluation before starting hormones and/or
surgery
50 20.8
None of the above 87 36.2
Distrust and isolating behaviors exhibited by AYAs�251
Expressed distrust of information about gender dysphoria and transgenderism
coming from mainstream doctors and psychologists
130 51.8
Tried to isolate themselves from their family 124 49.4
Expressed that they ONLY trust information about gender dysphoria and
transgenderism that comes from transgender websites and/or transgender
people and sources
117 46.6
Lost interest in activities where participants aren’t predominantly transgender
or LGBTIA
81 32.3
Lost interest in activities that were not related to transgender or LGBTIA issues 65 25.9
Stopped spending time with friends who are not transgender 63 25.1
Expressed distrust of people who are not transgender 57 22.7
Expressed hostility towards people who are not transgender 46 18.3
None of the above 44 17.5
Other behavior and outcomes for AYAs�249
Withdrawn from family 112 45.0
Told other people or posted on social media that their parent is
“transphobic”, “abusive”, or “toxic” because the parent does not
agree with the child’s assessment of being transgender
107 43.0
Refused to speak to parent 71 28.5
Defended the practice of lying to or withholding information from therapists or
doctors in order to obtain hormones for transition more quickly
41 16.5
Tried to run away 17 6.8
Been unable to obtain a job 25 10.0
Been unable to hold a job 18 7.2
Dropped out of college 12 4.8
Dropped out of high school 12 4.8
Needed to take a leave of absence from college 12 4.8
Been fired from a job 9 3.6
Needed a leave of absence from high school 1 0.4
None of the above 86 34.5
For any of the above, is this a significant change from
the child’s baseline behavior?
161
Yes 115 71.4
No 46 28.6
�may select more than one answer.
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were considered significant changes from the child’s baseline behaviors for 71.4% of respon-
dents checking any of the items.
There was a subset of eight cases where parents described watching their child have declin-
ing mental well-being as they became gender dysphoric and transgender-identified and then
had improving mental well-being as they dropped or backed away from a transgender-identifi-
cation. One parent described a marked change in her daughter when she was out of school
temporarily. “[Her] routine was disrupted. She spent all day on the internet, and lost her many
school friends—her only friends were on-line and members of the trans community. In three
months, my daughter announced she is trans, gender dysphoric, wants binders and top sur-
gery, testosterone shots. . .she started self-harming. Now back at school. . .she tweeted that
she’s so young, isn’t sure if she is trans, no longer wants to be referred to by the male name she
had chosen. . .Since she has started back at school and is being exposed to a wide variety of
people she is WAY happier.” Another parent described, “My daughter’s insight has improved
considerably over the last few years, and she has also outgrown the belief that she is transgen-
der. My daughter actually seemed to be looking for a reason for her depression which is now
being successfully treated. . .My daughter is MUCH happier now that she is being treated for
her genuine issues. Coming out as trans made her much worse for a while.”
There was a subset of 30 cases where the AYAs’ transgender-identification occurred in the
context of a decline in their ability to function (such as dropping out of high school or college,
needing a leave of absence from high school or college, and/or being unable to obtain or hold a
job), which parents reported as a significant change from their child’s baseline behavior. The
declines were substantial as 43.3% of these AYAs had been identified as academically gifted
students (some described as top of their class in high school, earning outstanding grades at
prestigious universities) before they began to fail their classes, drop out of high school or col-
lege, and became unable to hold a job. In most of these cases (76.7%), there was one or more
psychiatric diagnosis made at the same time or within the year (60.0%) or within two years
(16.7%) of the AYA’s new transgender-identification. Of the 23 individuals who had a psychi-
atric diagnosis made within two years of assuming a transgender-identification, 91.3% (21/23)
were diagnosed with depression; 73.9% (17/23) with anxiety; 26.0% (6/23) with bipolar disor-
der; 17.4% (4/23) with borderline personality disorder; 8.7% (2/23) with psychosis/psychotic
episode: and 8.7% (2/23) with an eating disorder.
Clinical encounters
Parents were asked if their child had seen a gender therapist, gone to a gender clinic, or seen a
physician for the purpose of beginning transition and 92 respondents (36.2%) answered in the
affirmative (Table 11). Many of the respondents clarified that their child had seen a clinician
regarding their gender dysphoria for evaluation only. Although participants were not asked
directly what kind of provider their child saw, specialties that were mentioned in answers
included: general psychologists, pediatricians, family doctors, social workers, gender therapists,
and endocrinologists. For parents who knew the content of their child’s evaluation, 71.6%
reported that the clinician did not explore issues of mental health, previous trauma, or any alter-
native causes of gender dysphoria before proceeding and 70.0% report that the clinician did not
request any medical records before proceeding. Despite all of the AYAs in this study sample
having an atypical presentation of gender dysphoria (no gender dysphoria prior to puberty),
23.8% of the parents who knew the content of their child’s visit reported that the child was
offered prescriptions for puberty blockers and/or cross-sex hormones at the first visit.
One participant described, “For the most part, I was extremely frustrated with providers
NOT acknowledging the mental disorder, anxiety, depression, etc before recommending
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hormone replacement therapy.” And two participants described how the clinician treating
their child’s gender dysphoria refused to speak with the patients’ primary care physicians. One
participant said, “When we phoned the clinic, the doctor was hostile to us, told us to mind our
own business. Our family doctor tried to reach our son’s new doctor, but the trans doctor
refused to speak with her.” Another respondent shared “The pediatrician/‘gender specialist’
did not return calls or emails from the primary care physician who requested to talk with her
about my son’s medical history before she saw and treated him. . .she disregarded all historical
information provided by the family and primary care physician. . .did not verify any informa-
tion provided by my. . .son at his first visit even after being provided with multiple other his-
torical sources which differed significantly from his story.”
When asked about whether their child relayed their history completely and accurately to
clinicians or whether they misrepresented or omitted parts of their history, of those who knew
the content of their child’s visit, 84.2% of the parent respondents were reasonably sure or posi-
tive that their child had misrepresented or omitted parts of their history. Twenty-eight partici-
pants provided optional open text responses to this question and the responses were
categorized into: describing how the parent knew that the child misrepresented their history
Table 11. Interactions with clinicians.
n %
Did the AYA see a gender therapist, go to a gender
clinic or see a physician for the purpose of transition?
254
No 151 59.4
Yes 92 36.2
Don’t know 11 4.3
Did the therapist/physician/clinic staff explore issues
of mental health, previous trauma, or any alternative causes
of gender dysphoria before proceeding?
100
Yes 21 21.0
No 53 53.0
Don’t know 26 26.0
Did the therapist/physician/clinic staff request any
medical records before proceeding?
99
Yes 21 21.2
No 49 49.5
Don’t know 29 29.3
Of parents who knew the content of the visit, did the
AYA receive an Rx for puberty blockers and/or
cross-sex hormones at their first visit?
80
AYA received an Rx for puberty blockers and/or cross-sex
hormones at their first visit
17 21.2
AYA was offered a Rx for puberty blockers and/or
cross-sex hormones at their first visit, but AYA or parent declined
2 2.5
Total number of AYAs who received or were offered an Rx at first visit 19 23.8
AYAs who did not receive/were not offered an Rx at their first visit 61 76.2
Did AYA misrepresent their history to the doctor or relay
their history accurately?
96
Parent is reasonably sure or positive that their child misrepresented or
omitted parts of their history
64 66.7
Parent is reasonable sure or positive that their child relayed their history
completely and accurately
12 12.5
Don’t know 20 20.8
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(5); the content of what the child misrepresented (6 misrepresenting in general, 4 misrepre-
senting to the clinician for a total of 10 examples); don’t know/not sure (4); expressing cer-
tainty (1); and not relevant (8). For the five participants describing how they knew, the reasons
included: being present when it happened, reading the report from the gender specialist, being
told by their child that the child had misrepresented the truth, and being informed by the
child’s psychiatrist. One respondent shared, “I have read the report from the gender specialist
and it omits all the relevant context painting an almost unrecognizable picture of my son.” A
second parent simply responded, “I was present.” Another respondent relayed about their
(natal male) child, “My daughter told me and her mother that the first therapist she saw asked
her stereotypical questions. . .She was afraid that if she didn’t describe herself as a ‘typical girl’
she would not be believed.” And finally, one respondent wrote, “He has said now that he did
[misrepresent his history] and used key words he was advised to say.” Ten participants pro-
vided 13 examples of the content of misrepresentations and of these, 6 examples could have
been easily verified to be false (claiming to be under the care of a psychiatrist, claiming to be
on medication to treat a psychiatric condition, how one was doing academically, and claiming
a childhood history of having playmates of one sex when the opposite was observed, and
claiming strong childhood preferences for specific toys and clothing that is the opposite of
what multiple individuals observed). Three of the content examples would have been challeng-
ing to verify as false including: how one was feeling as a child, how one was feeling when a pic-
ture was taken, and whether one was from an abusive home. And four of the content examples
did not provide enough information to determine if they would be easy or challenging to verify
as false, such as “My child distorts her history and our family life on a regular basis,” and “He
has created an entire narrative that just isn’t true.”
In addition to the previously mentioned case where the child literally rewrote her history by
editing her diary, there were seven respondents who conveyed a process where their child was
constantly rewriting their personal history to make it consistent with the idea that they always
were transgender and/or had created a childhood history that was not what others had
observed. It is unclear whether this process was deliberate or if the individuals were unaware
of their actions. The following are quotes describing this phenomenon. One parent said,
“. . .she is actively rewriting her personal history to support the idea that she was always trans.”
Another respondent added,”. . .my daughter denies events I recollect from her childhood and
puberty that contradicts her narrative of ‘always knowing she was a boy.’” Another respondent
offered, “He is rewriting his personal history to suit his new narrative.” And a fourth respon-
dent described, “[Our] son has completely made up his childhood to include only girl friends
and dressing up in girls clothes and playing with dolls, etc. This is not the same childhood we
have seen as parents.”
Qualitative analysis
The open-ended comments from the question about whether the clinician explored mental
health, trauma or alternative causes of gender dysphoria before proceeding were selected for
qualitative analysis. Nine major themes emerged from the data. Each theme is described in the
following paragraphs with supporting quotes from participants.
Theme: Failure to explore mental health, trauma or alternative causes of GD. Parents
described that clinicians failed to explore their child’s mental health, trauma, or any alternative
causes for the child’s gender dysphoria. This failure to explore mental health and trauma
occurred even when patients had a history of mental health disorder or trauma, were currently
being treated for a mental health disorder, or were currently experiencing symptoms. One par-
ticipant said, “Nothing other than gender dysphoria was considered to explain my daughter’s
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desire to transition.” Another participant said, “My daughter saw a child therapist and the
therapist was preparing to support transgendering and did not explore the depression and anx-
iety or previous trauma.”
Theme: Insufficient evaluation. Another theme was insufficient evaluation where
parents described evaluations that were too limited or too superficial to explore mental health,
trauma or alternative causes of gender dysphoria. The following are three quotes by three dif-
ferent parents describing insufficient evaluations. One parent said, “The exploration was egre-
giously insufficient, very shallow, no effort to ask questions, engage in critical thinking about
coexisting anxiety, or put on the brakes or even slow down.” Another participant stated,
“When we tried to give our son’s trans doctor a medical history of our son, she refused to
accept it. She said the half hour diagnosis in her office with him was sufficient, as she considers
herself an expert in the field.” And a third parent wrote, “We were STUNNED by the lack of
information, medical history sought by therapist and radical treatment suggestion. [One ]visit.
The idea is, ‘if they say they were born in the wrong body, they are. To question this will only
hurt her and prolong her suffering.’ [Our] daughter has had trauma in [the] past. [She] never
was asked about it. [The] therapist did not ask parents a single question about our daughter.”
Theme: Unwillingness or disinterest in exploring mental health, trauma or alternative
causes of GD. Parents described that clinicians did not seem interested or willing to explore
alternative causes. One parent described. “Her current therapist seems to accept her self diag-
nosis of gender dysphoria and follows what she says without seeming too much interested in
exploring the sexual trauma in her past.” Another parent wrote, “The Asperger psychiatrist did
not seem to care whether our daughter’s gender dysphoria stemmed from Asperger’s. If our
daughter wanted to be male, then that was enough.” And a third parent said. “The therapist
did ask about those issues but seemed to want to accept the idea wholeheartedly that my
daughter was transgender first and foremost, all other factors aside.”
Theme: Mental health was explored. A few parents had the experience where the clini-
cian either made an appropriate referral for further evaluation or the issues had been addressed
previously. One parent said, “[The] previous mental health issues [were] already explored by
other therapists ([my] child was in therapy and medicated before coming out as transgender).”
Theme: Failure to communicate with patients’ medical providers. Several participants
described clinicians who were unwilling to communicate with primary care physicians and
mental health professionals even those professionals who were currently treating the patient.
One participant relayed, “She did not review the extensive psychiatric records that were avail-
able in a shared EMR [electronic medical record] and she did not consult with his outpatient
psychiatrist prior to or after starting cross-sex hormonal therapy.” Another parent said, “My
child had been seen for mental health issues for several years before presenting this new iden-
tity, but the endocrinologist did not consult the mental health professionals for their opinions
before offering hormones.”
Theme: Misrepresentation of information by the patient. Several participants described
how their child misrepresented their history to the clinician, thus, limiting the clinician’s ability
to adequately explore mental health, trauma and alternative causes. One participant wrote, “At
[the] first visit, [my] daughter’s dialogue was well-rehearsed, fabricated stories about her life told
to get [the] outcome she desired. She parroted people from the internet.” Another parent
reported, “My son concealed the trauma and mental health issues that he and the family had
experienced.” And a third parent said, “I overheard my son boasting on the phone to his older
brother that ‘the doc swallowed everything I said hook, line and sinker. Easiest thing I ever did.’”
Theme: Transition steps were pushed by the clinician. Some parents described clini-
cians who seemed to push the process of transition before the patient asked for it. One parent
described that the doctor gave her daughter a prescription that she didn’t ask for, “The family
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doctor who gave her the Androgel Rx [prescription] did NOT ask her many questions (she
was surprised by this), nor did he await her assessment by a licensed psychiatrist before giving
her this Rx. Nor did she ask him for this Rx.” Another parent reported that she and her child
were at the endocrinologist’s office only to ask questions, and described, “. . .[he] didn’t listen
to a word we were saying. He was too eager to get us set up with a ‘gender therapist’ to get the
legal form he needed to start hormones, all while making sure we set up our next appointment
within 6 months to start the hormones. . .”
Theme: Parent views were discounted or ignored. Parents describe that the clinicians
did not take their concerns seriously. One parent described, “I have to say I don’t know, but it
is hard to believe that they adequately examined the history of bullying and being ostracized
for being different, and the autistic traits that would lend a person like my son to risk every-
thing for identifying with a group. I know that in the few contacts I had with the providers, my
concerns were discounted.” And another said, “All of our emails went unanswered and were
ignored. We are left out of everything because of our constant questioning of this being right
for our daughter [because of her] trauma and current depression, anxiety and self-esteem
problems.”
Theme: Parent had concerns about the clinicians’ competence, professionalism or expe-
rience. Parents expressed doubts about the clinicians regarding their experience, competence or
professionalism. One parent said, “The clinic told me they explored these issues. I asked the risk
manager at [redacted] if they’d considered a personality disorder. ‘Oh, no,’ she laughed. ‘That’s
only with the older patients, not the teenagers.’ I’m deeply suspicious of their competence.”
Another parent described, “What does concern me is that the people she talked to seemed to
have no sense of professional duties, but only a mission to promote a specific social ideology.”
Steps towards transition and current identification status
This section reports on the duration of AYA transgender-identification (time from the AYA’s
announcement of a transgender identity until the time the parent completed the survey) that
covers, on average, 15.0 months (range 0.1–120 months) with a median of 11 months
(Table 12). The steps taken towards transition during this timeframe are listed in Table 12. At
the end of the timeframe, 83.2% of the AYAs were still transgender-identified, 5.5% were not
still transgender-identified (desisted), 2.7% seemed to be backing away from transgender-iden-
tification, and 8.6% of the parents did not know if their child was still identifying as transgender.
Descriptions of backing away or moving from transgender-identified to not transgender-identi-
fied include the following. One parent observed, “She identified as trans for six months . . . Now
back at school, she is thinking maybe she’s not trans.” Another parent offered, “My daughter
[identified] as trans from ages 13–16. She gradually desisted as she developed more insight into
who she is.” One parent described that after one year of identifying as transgender, “basically,
she changed her mind once she stopped spending time with that particular group of friends.”
The duration of transgender-identification of the AYAs who were still transgender-identified at
the time of survey was compared to the duration of those who were no longer transgender-iden-
tified and those who seemed to be backing away from a transgender-identification (combined)
by t-test. The difference between these groups was statistically significant (p = .025), with a t-
value of -2.25 showing that those who were no longer transgender-identified and backing away
had a longer duration of identification (mean = 24.1 months) and those who were still transgen-
der-identified had a shorter mean duration (mean = 14.4 months).
To explore the differences between the AYAs who had exposure to social influence (friend
group, internet/social media, or both) and AYAs who did not have a clear exposure to social
influence (neither and don’t know), a series of chi-squared calculations were performed for
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selected variables. (See Table 13.) Statistically significant differences were revealed for AYAs
with exposure to social influences having worse outcomes for mental well-being and parent-
child relationships, and greater numbers exhibiting distrust, isolating and anti-social behaviors
including: narrowed range of interests and hobbies, expressing that they only trusted informa-
tion from transgender sources, trying to isolate themselves from their family, losing interest in
activities that weren’t predominantly with transgender or LGBTIA participants, and telling
people or posting on social media that their parent is “transphobic,” “abusive,” or “toxic”
because the parent doesn’t agree with the child’s assessment of being transgender. Although
the differences in additional isolating and anti-social behaviors did not reach statistical signifi-
cance, these behaviors trended towards higher rates in the AYAs who were exposed to social
influence and may have not reached significant levels due to small numbers. No significant dif-
ference for age of AYA (at announcement or at time of survey completion) was detected
between groups by a one-way ANOVA.
Discussion
This research describes parental reports about a sample of AYAs who would not have met
diagnostic criteria for gender dysphoria during their childhood but developed signs of gender
dysphoria during adolescence or young adulthood. The strongest support for considering that
the gender dysphoria was new in adolescence or young adulthood is the parental answers for
Table 12. Transition steps and disposition.
n %
Transition Steps�256
Changed hairstyle 216 84.4
Changed style of clothing 210 82.0
Asks to be called a new name 188 73.4
Asks for different pronouns 175 68.4
Taken cross-sex hormones 29 11.3
Legally changed name on government documents 19 7.4
Taken anti-androgens 11 4.3
Taken puberty blockers 7 2.7
Had surgery 5 2.0
None of the above 14 5.5
Disposition 256
Still transgender-identified 213 83.2
Not transgender-identified any more (desisted) 14 5.5
Seems to be backing away from transgender-identification 7 2.7
Parent doesn’t know if the child is still transgender-identified 22 8.6
De-transitioned (also counted in desisted category) 3 1.2
Duration of transgender-identification overall Median duration 11 months, Mean duration 15.0 months
(range 0.1 months-120 months), median 11 months
225
Duration of transgender-identification if still
transgender-identified
Median duration 11 months, mean duration 14.4 months,
ange (0.1 months-72 months)
204
Duration of transgender-identification if no longer
transgender-identified
Median duration 12 months, mean duration 24.2 months,
range (.75 months to 120 months)
13
Duration of transgender-identification if backing away Median duration 12 months, mean duration 15 months,
range (3 months-36 months)
8
�may select more than one answer.
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DSM 5 criteria for childhood gender dysphoria. Not only would none of the sample have met
threshold criteria, the vast majority had zero indicators. Although one might argue that three
of the indicators could plausibly be missed by a parent (A1, A7, and A8 if the child had not
Table 13. chi-squared comparisons for exposure to social influence (SI) vs not exposure to social influence (NSI).
SI
n (%)
NSI
n (%)
p
Sex 222 34 .123
Female 187 (84.2) 25 (73.5)
Male 35 (15.8) 9 (26.5)
Indicators of childhood GD 221 33 .004
0–2 indicators 216 (97.7) 29 (87.9)
3–4 indicators 5 (2.3) 4 (12.1)
Currently have two or more GD indicators 214 34 .808
Yes 179(83.6) 29 (85.3)
No 35(16.4) 5(14.7)
No mental health or NDD diagnoses before onset of GD 222 34 .036
Answered “None of the above” 87(39.9) 7 (20.6)
Mental well-being since announcement 220 33 .001
Worse 114 (51.8) 6 (18.2)
Better 24 (10.9) 8 (24.2)
Unchanged/Mixed 82 (37.3) 19 (57.6)
Parent-child relationship since announcement 219 33 .006
Worse 134 (61.2) 11 (33.3)
Better 13 (5.9) 5 (15.2)
Unchanged/Mixed 72 (32.9) 17 (51.5)
Range of interests and hobbies 220 34 <0.001
Broader range of interests and hobbies 10 (4.5) 3 (8.8)
Narrowed range of interest and hobbies 139 (63.2) 9 (26.5)
Unchanged range 71 (32.3) 22 (64.7)
Distrust and Isolating Behaviors 222 34
Tried to isolate themselves from family 114(51.4) 10 (29.4) .017
Expressed that they ONLY trust information about
GD and transgenderism that comes from transgender sources
107 (48.2) 10 (29.4) .041
Lost interest in activities where participants aren’t
predominantly transgender or LGBTIA
76 (34.2) 5 (14.7) .023
Stopped spending time with non-transgender friends 59 (26.6) 4 (11.8) .062
Expressed distrust of people who are not transgender 52 (23.4) 5 (14.7) .255
Told people or posted on social media that their parent is
“transphobic,” “abusive,” or “toxic” because the parent
doesn’t agree with the child’s assessment of being transgender
102 (45.9) 5 (14.7) <0.001
Defended the practice of lying to or withholding information from
doctors/therapists to get hormones for transition more quickly
38 (17.1) 3 (8.8) .219
Brought up the issue of suicide in transgender teens as a reason
parents should agree to treatment
55 (24.8) 4 (11.8) .093
Did the AYA misrepresent their history
to the doctor or relay it accurately?
68 8 .075
Parent is reasonable sure or positive that their child misrepresented or
omitted parts of their history
59 (86.8) 5 (62.5)
Parent is reasonable sure or positive that child relayed
their history completely and accurately
9 (13.2) 3 (37.5)
https://doi.org/10.1371/journal.pone.0202330.t013
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expressed these verbally), five of the indicators (A2-6) are readily observable behaviors and
preferences that would be difficult for a parent to miss. Six indicators (including A1) are
required for a threshold diagnosis. The nonexistent and low numbers of readily observable
indicators reported in the majority of this sample does not support a scenario in which gender
dysphoria was always present but was only recently disclosed to the parents.
Parents reported that before the onset of their gender dysphoria, many of the AYAs had
been diagnosed with at least one mental health disorder or neurodevelopmental disability and
many had experienced a traumatic or stressful event. Experiencing a sex or gender related
trauma was not uncommon, nor was experiencing a family stressor (such as parental divorce,
death of a parent, or a mental health disorder in a sibling or parent). Additionally, nearly half
were described as having engaged in self-harm prior to the onset of their gender dysphoria. In
other words, many of the AYAs and their families had been navigating multiple challenges and
stressors before gender dysphoria and transgender-identification became part of their lives.
This context could possibly contribute to friction between parent and child and these complex,
overlapping difficulties as well as experiences of same-sex attraction may also be influential in
the development of a transgender identification for some of these AYAs. Care should be taken
not to overstate or understate the context of pre-existing diagnoses or trauma in this popula-
tion as they were absent in approximately one third and present in approximately two thirds
of the sample.
This research sample of AYAs also differs from the general population in that it is predomi-
nantly natal female, white, and has an over-representation of individuals who are academically
gifted, non-heterosexual, and are offspring of parents with high educational attainment [59–
61]. The sex ratio favoring natal females is consistent with recent changes in the population of
individuals seeking care for gender dysphoria. Gender clinics have reported substantial
increases in referrals for adolescents with a change in the sex ratio of patients moving from
predominantly natal males seeking care for gender dysphoria to predominantly natal females
[26–28,62]. Although increased visibility of transgender individuals in the media and avail-
ability of information online, with a partial reduction of stigma might explain some of the rise
in the numbers of adolescents presenting for care [27], it would not directly explain why the
inversion of the sex ratio has occurred for adolescents but not adults or why there is a new phe-
nomenon of natal females experiencing late-onset and adolescent-onset gender dysphoria.
The unexpectedly high rate of academically gifted AYAs may be related to the high educational
attainment of the parents and may be a reflection of parents who are online, able to complete
online surveys and are able to question and challenge current narratives about gender dyspho-
ria and transition. There may be other unknown variables that render academically gifted
AYAs susceptible to adolescent-onset and late-onset gender dysphoria. The higher than
expected rate of non-heterosexual orientations of the AYAs (prior to announcement of a trans-
gender-identity) may suggest that the desire to be the opposite sex could stem from experienc-
ing homophobia as a recent study showed that being the recipient of homophobic name
calling from one’s peers was associated with a change in gender identity for adolescents [63].
The potential relationship of experienced homophobia and the development of a rapid onset
of gender dysphoria during adolescence or young adulthood as perceived by parents deserves
further study.
This sample is distinctively different than what is described in previous research about gen-
der dysphoria because of the distribution of cases occurring in friendship groups with multiple
individuals identifying as transgender, the preponderance of adolescent (natal) females, the
absence of childhood gender dysphoria, and the perceived suddenness of onset. In this study,
parental reports of transgender identification duration in AYAs suggest that in some cases
(~8% in this study) gender dysphoria and transgender-identification may be temporary, and
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that longer observation periods may be needed to assess such changes. Further research is
needed to verify these results. There have been anecdotal reports of adolescents who desisted
approximately 9–36 months after showing signs of a rapid onset of gender dysphoria, but lon-
gitudinal research following AYAs with gender dysphoria would be necessary to study desis-
tance trends. Although it is still unknown whether transition in gender dysphoric individuals
decreases, increases, or fails to change the rates of attempted or completed suicides [64], this
study documents AYAs using a suicide narrative as part of their arguments to parents and doc-
tors towards receiving support and transition services. Despite the possibility that the AYAs
are using a suicide narrative to manipulate others, it is critical that any suicide threat, ideation
or concern is taken seriously and the individual should be evaluated immediately by a mental
health professional.
The majority of parents were reasonably sure or certain that their child misrepresented or
omitted key parts of their history to their therapists and physicians. In some cases, the misrep-
resentation of one’s history may simply be a deliberate act by a person who is convinced that
transition is the only way that they will feel better and who may have been coached that lying is
the only way to get what they think they need. For others, the misrepresentation may not be a
conscious act. The creation of an alternate version of one’s childhood that conforms to a story
of always knowing one was transgender and that is in sharp contrast to the childhood that was
observed by third parties raises the question of whether there has been the creation of false
childhood memories as part of, or outside of, the therapy process. Respondent accounts of cli-
nicians who ignored or disregarded information (such as mental health symptoms and diagno-
ses, medical and trauma histories) that did not support the conclusion that the patient was
transgender, suggests the possibility of motivated reasoning and confirmatory biases on the
part of clinicians. In the 1990s, the beliefs and practices of many mental health professionals
may have contributed to their patients’ creation of false childhood memories consistent with a
child sexual abuse narrative and research since then has shown that false childhood memories
of mundane events can be implanted in laboratory settings [65–67]. It may be worthwhile to
explore if, in today’s culture, there might be beliefs and practices of some mental health profes-
sionals that are contributing to their patients’ creation of false childhood memories consistent
with an “always knew/always were transgender” narrative.
Emerging hypotheses
Hypothesis 1: Social influences can contribute to the development of
gender dysphoria
It is unlikely that friends and the internet can make people transgender. However, it is plausi-
ble that the following can be initiated, magnified, spread, and maintained via the mechanisms
of social and peer contagion: (1) the belief that non-specific symptoms (including the symp-
toms associated with trauma, symptoms of psychiatric problems, and symptoms that are part
of normal puberty) should be perceived as gender dysphoria and their presence as proof of
being transgender; 2) the belief that the only path to happiness is transition; and 3) the belief
that anyone who disagrees with the self-assessment of being transgender or the plan for transi-
tion is transphobic, abusive, and should be cut out of one’s life. The spread of these beliefs
could allow vulnerable AYAs to misinterpret their emotions, incorrectly believe themselves to
be transgender and in need of transition, and then inappropriately reject all information that
is contrary to these beliefs. In other words, “gender dysphoria” may be used as a catch-all
explanation for any kind of distress, psychological pain, and discomfort that an AYA is feeling
while transition is being promoted as a cure-all solution.
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One of the most compelling findings supporting a potential role of social and peer conta-
gion in the development or expression of a rapid onset of gender dysphoria is the clusters of
transgender-identification occurring within friendship groups. The expected prevalence of
transgender young adult individuals is 0.7% [8]. Yet, according to the parental reports, more
than a third of the friendship groups described in this study had 50% or more of the AYAs in
the group becoming transgender-identified in a similar time frame. This suggests a localized
increase to more than 70 times the expected prevalence rate. This is an observation that
demands urgent further investigation. One might argue that high rates of transgender-identi-
fied individuals within friend groups may be secondary to the process of friend selection:
choosing transgender-identified friends deliberately rather than the result of group dynamics
and observed coping styles contributing to multiple individuals, in a similar timeframe, start-
ing to interpret their feelings as consistent with being transgender. More research will be
needed to finely delineate the timing of friend group formation and the timing and pattern of
each new declaration of transgender-identification. Although friend selection may play a role
in these high percentages of transgender-identifying members in friend groups, the described
pattern of multiple friends (and often the majority of the friends in the friend group) becoming
transgender-identified in a similar timeframe suggests that there may be more than just friend
selection behind these elevated percentages.
There are many insights from our understanding of peer contagion in eating disorders and
anorexia that may apply to the potential role(s) of peer contagion in the development of gender
dysphoria. Just as friendship cliques can set the level of preoccupation with one’s body, body
image, weight, and techniques for weight loss [37–39], so too may friendship cliques set a level
of preoccupation with one’s body, body image, gender, and the techniques to transition. The
descriptions of pro-anorexia subculture group dynamics where the thinnest anorexics are
admired while the anorexics who try to recover from anorexia are ridiculed and maligned as
outsiders [39–41] resemble the group dynamics in friend groups that validate those who iden-
tify as transgender and mock those who do not. And the pro-eating-disorder websites and
online communities providing inspiration for weight loss and sharing tricks to help individuals
deceive parents and doctors [42–44] may be analogous to the inspirational YouTube transition
videos and the shared online advice about manipulating parents and doctors to obtain
hormones.
Hypothesis 2: Parental conflict might provide alternative explanations for
selected findings
Parents reported subjective declines in their AYAs’ mental health and in parent-child relation-
ships after the children disclosed a transgender identification. Additionally, per parent report,
almost half of the AYAs withdrew from family, 28.5% refused to speak to a parent, and 6.8%
tried to run away. It is possible that some of these findings might be secondary to parent-child
conflict. Parent-child conflict could arise from disagreement over the child’s self-assessment of
being transgender. It is also possible that some parents might have had difficulty coping or
could have been coping poorly or maladaptively with their child’s disclosure. Other potential
explanations for the above findings include worsening of AYAs’ pre-existing (or onset of new)
psychiatric conditions or the use of maladaptive coping mechanisms. To further evaluate these
possibilities, future studies should incorporate information about family dynamics, parent-
child interactions, parent coping, child coping, and psychiatric trajectories. This study did not
collect data about the parents’ baseline coping styles, how they were coping with their child’s
disclosure, and whether their coping seemed to be maladaptive or adaptive. Nor did it explore
parents’ mental well-being. Future studies should explore these issues as well.
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Although most parents reported an absence of childhood indicators for gender dysphoria,
it is possible that these indicators might have existed for some of the AYAs and that some
parents either failed to notice or ignored these indicators when they occurred. Because the
readily observable indicators could also have been observed by other people in the child’s life,
future studies should include input from parents, AYAs and from third party informants such
as teachers, pediatricians, mental health professionals, babysitters, and other family members
to verify the presence or absence of readily observable behaviors and preferences during child-
hood. Parental approaches to their child’s gender dysphoria might contribute to specific out-
comes. This study did not specifically explore parental approaches to gender dysphoria or
parental views on medical or surgical interventions. Additional studies that explore whether
parents support or don’t support: gender exploration; gender nonconformity; non-heterosex-
ual sexual identities; mental health evaluation and treatment; and exploration of potential
underlying causes for dysphoria would be extremely valuable. It would also be worthwhile to
explore whether parents favor affirming the child as a person or affirming the child’s gender
identity and whether parents hold liberal, cautious, or negative views about the use of medical
and surgical interventions for gender dysphoria in AYAs.
Hypothesis 3: Maladaptive coping mechanisms may underlie the
development of gender dysphoria for some AYAs
For some individuals, the drive to transition may represent an ego-syntonic but maladaptive
coping mechanism to avoid feeling strong or negative emotions similar to how the drive to
extreme weight loss can serve as an ego-syntonic but maladaptive coping mechanism in
anorexia nervosa [68–69]. A maladaptive coping mechanism is a response to a stressor that
might relieve the symptoms temporarily but does not address the cause of the problem and
may cause additional negative outcomes. Examples of maladaptive coping mechanisms
include the use of alcohol, drugs, or self-harm to distract oneself from experiencing painful
emotions. One reason that the treatment of anorexia nervosa is so challenging is that the drive
for extreme weight loss and weight loss activities can become a maladaptive coping mechanism
that allows the patient to avoid feeling and dealing with strong emotions [69–70]. In this con-
text, dieting is not felt as distressing to the patient, because it is considered by the patient to be
the solution to her problems, and not part of the problems. In other words, the dieting and
weight loss activities are ego-syntonic to the patient. However, distress is felt by the patient
when external actors (doctors, parents, hospital staff) try to interfere with her weight loss activ-
ities thus curtailing her maladaptive coping mechanism.
Findings that may support a maladaptive coping mechanism hypothesis include that the
most likely description of AYA ability to use negative emotions productively was poor/
extremely poor and the majority of AYAs were described as “overwhelmed by strong emotions
and tries to/goes to great lengths to avoid experiencing them.” Although these are not validated
questions, the findings suggest, at least, that there is a history of difficulty dealing with emo-
tions. The high frequency of parents reporting AYA expectations that transition would solve
their problems coupled with the sizable minority who reported AYA unwillingness to work on
basic mental health issues before seeking treatment support the concept that the drive to tran-
sition might be used to avoid dealing with mental health issues and aversive emotions. Addi-
tional support for this hypothesis is that the sample of AYAs described in this study are
predominantly female, were described by parents as beginning to express symptoms during
adolescence and contained an overrepresentation of academically gifted students which bears
a strong resemblance to populations of individuals diagnosed with anorexia nervosa [71–75].
The risk factors, mechanisms and meanings of anorexia nervosa [69–70,76] may ultimately
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prove to be a valuable template to understand the risk factors, mechanisms, and meanings for
some cases of gender dysphoria.
Transition as a drive to escape one’s gender/sex, emotions, or difficult realities might also
be considered when the drive to transition arises after a sex or gender-related trauma or within
the context of significant psychiatric symptoms and decline in ability to function. Although
trauma and psychiatric disorders are not specific for the development of gender dysphoria,
these experiences may leave a person in psychological pain and in search of a coping mecha-
nism. The first coping mechanism that a vulnerable person adopts may be the result of their
environment and which narratives for pain and coping are most prevalent in that environ-
ment—in some settings a gender dysphoria/drive to transition may be the dominant para-
digm, in some settings a body dysphoria/drive for extreme weight loss is dominant, and in
another the use of alcohol and drugs to cope with pain may be dominant. Because maladaptive
coping mechanisms do not address the root cause of distress and may cause their own negative
consequences, an outcome commonly reported for this sample, AYAs experiencing a decline
in their mental well-being after transgender-identification, is consistent with this hypothesis.
There was a subset of AYAs for whom parents reported improvement in their mental well-
being as they desisted from their transgender-identification which would not be inconsistent
with moving from a maladaptive coping mechanism to an adaptive coping mechanism.
If the above hypotheses are correct, rapid onset of gender dysphoria that is socially medi-
ated and/or used as a maladaptive coping mechanism may be harmful to AYAs in the follow-
ing ways: (1) non-treatment or delayed treatment for trauma and mental health problems that
might be the root of (or at least an inherent part of) the AYAs’ issues; (2) alienation of the
AYAs from their parents and other crucial social support systems; (3) isolation from main-
stream, non-transgender society, which may curtail educational and vocational potential; and
(4) the assumption of the medical and surgical risks of transition without benefit. In addition
to these indirect harms, there is also the possibility that this type of gender dysphoria, with the
subsequent drive to transition, may represent a form of intentional self-harm. Promoting the
affirmation of a declared gender and recommending transition (social, medical, surgical) with-
out evaluation may add to the harm for these individuals as it can reinforce the maladaptive
coping mechanism, prolong the length of time before the AYA accepts treatment for trauma
or mental health issues, and interfere with the development of healthy, adaptive coping mecha-
nisms. It is especially critical to differentiate individuals who would benefit from transition
from those who would be harmed by transition before proceeding with treatment.
Reflections
Clinicians need to be aware of the myriad of barriers that may stand in the way of making
accurate diagnoses when an AYA presents with a desire to transition including: the develop-
mental stage of adolescence; the presence of subcultures coaching AYAs to mislead their doc-
tors; and the exclusion of parents from the evaluation. In this study, 22.3% of AYAs were
reported as having been exposed to online advice about what to say to doctors to get hor-
mones, and 17.5% to the advice that it is acceptable to lie to physicians; and the vast majority
of parents were reasonably sure or positive that their child misrepresented their history to
their doctor or therapist. Furthermore, although parents may be knowledgeable informants on
matters of their own child’s developmental, medical, social, behavioral, and mental health his-
tory- and quite possibly because they are knowledgeable- they are often excluded from the clin-
ical discussion by the AYAs, themselves. An AYA telling their clinician that their parents are
transphobic and abusive may indeed mean that the parents are transphobic and abusive. How-
ever, the findings of this research indicate that it is also possible that the AYA calls the parent
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transphobic and abusive because the parent disagrees with the child’s self-diagnosis, has
expressed concern for the child’s future, or has requested that the child be evaluated for mental
health issues before proceeding with treatment.
The findings of this study suggest that clinicians need to be cautious before relying solely
on self-report when AYAs seek social, medical or surgical transition. Adolescents and young
adults are not trained medical professionals. When AYAs diagnose their own symptoms based
on what they read on the internet and hear from their friends, it is quite possible for them to
reach incorrect conclusions. It is the duty of the clinician, when seeing a new AYA patient
seeking transition, to perform their own evaluation and differential diagnosis to determine if
the patient is correct or incorrect in their self-assessment of their symptoms and their convic-
tion that they would benefit from transition. This is not to say that the convictions of the
patient should be dismissed or ignored, some may ultimately benefit from transition. How-
ever, careful clinical exploration should not be neglected, either. The patient’s history being
significantly different than their parents’ account of the child’s history should serve as a red
flag that a more thorough evaluation is needed and that as much as possible about the patient’s
history should be verified by other sources. The findings that the majority of clinicians
described in this study did not explore trauma or mental health disorders as possible causes of
gender dysphoria or request medical records in patients with atypical presentations of gender
dysphoria is alarming. The reported behavior of clinicians refusing to communicate with their
patients’ parents, primary care physicians, and psychiatrists betrays a resistance to triangula-
tion of evidence which puts AYAs at considerable risk.
It is possible that some teens and young adults may have requested that their discussions
with the clinicians addressing gender issues be kept confidential from their parents, as is their
right (except for information that would put themselves or others at harm). However, main-
taining confidentiality of the patient does not prevent the clinician from listening to the medi-
cal and social history of the patient provided by the parent. Nor does it prevent a clinician
from accepting information provided by the patient’s primary care physicians and psychia-
trists. Because adolescents may not be reliable historians and may have limited awareness and
insight about their own emotions and behaviors, the inclusion of information from multiple
informants is often recommended when working with or evaluating minors. One would
expect that if a patient refuses the inclusion of information from parents and physicians (prior
and current), that the clinician would explore this with the patient and encourage them to
reconsider. At the very least, if a patient asks that all information from parents and medical
sources be disregarded, it should raise the suspicion that what the patient is presenting may be
less than forthcoming and the clinician should proceed with caution.
The argument to surface from this study is not that the insider perspectives of AYAs pre-
senting 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. All parents know their growing children are not always right, particularly
in the almost universally tumultuous period of adolescence. Most parents have the awareness
and humility to know that even as adults they are not always right themselves. When an AYA
presents with signs of a rapid onset of gender dysphoria it is incumbent upon all professionals
to fully respect the young person’s insider perspective but also, in the interests of safe diagnosis
and avoidance of clinical harm, to have the awareness and humility themselves to engage with
parental perspectives and triangulate evidence in the interest of validity and reliability.
The strengths of this study include that it is the first empirical description of a specific phe-
nomenon that has been observed by parents and clinicians [14] and that it explores parent
observations of the psychosocial context of youth who have recently identified as transgender
with a focus on vulnerabilities, co-morbidities, peer group interactions, and social media use.
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Additionally, the qualitative analysis of responses about peer group dynamics provides a rich
illustration of AYA intra-group and inter-group behaviors as observed and reported by
parents. This research also provides a glimpse into parent perceptions of clinician interactions
in the evaluation and treatment of AYAs with an adolescent-onset (or young adult-onset) of
gender dysphoria symptoms.
The limitations of this study include that it is a descriptive study and thus has the known
limitations inherent in all descriptive studies. This is not a prevalence study and does not
attempt to evaluate the prevalence of gender dysphoria in adolescents and young adults who
had not exhibited childhood symptoms. Likewise, this study’s findings did not demonstrate
the degree to which the onset of gender dysphoria symptoms may be socially mediated or asso-
ciated with a maladaptive coping mechanism, although these hypotheses were discussed here.
Gathering more data on the topics introduced is a key recommendation for further study. It is
not uncommon for first, descriptive studies, especially when studying a population or phe-
nomenon where the prevalence is unknown, to use targeted recruiting. To maximize the possi-
bility of finding cases meeting eligibility criteria, recruitment is directed towards communities
that are likely to have eligible participants. For example, in the first descriptive study about
children who had been socially transitioned, the authors recruited potential subjects from gen-
der expansive camps and gender conferences where parents who supported social transition
for young children might be present and the authors did not seek out communities where
parents might be less inclined to find social transition for young children appropriate [77]. In
the same way, for the current study, recruitment was targeted primarily to sites where parents
had described the phenomenon of a rapid onset of gender dysphoria because those might be
communities where such cases could be found. The generalizability of the study must be care-
fully delineated based on the recruitment methods, and, like all first descriptive studies, addi-
tional studies will be needed to replicate the findings.
Three of the sites that posted recruitment information expressed cautious or negative views
about medical and surgical interventions for gender dysphoric adolescents and young adults
and cautious or negative views about categorizing gender dysphoric youth as transgender. One
of the sites that posted recruitment information is perceived to be pro-gender-affirming.
Hence, the populations viewing these websites might hold different views or beliefs from each
other. And both populations may differ from a broader general population in their attitudes
about transgender-identified individuals. This study did not explore specific participant views
about medical and surgical interventions for gender dysphoric youth or whether participants
support or don’t support: exploration of gender identity, exploration of potential underlying
causes for gender dysphoria, affirmation of children as valued individuals or affirmation of
children’s gender identity. Future studies should explore all these issues. This study cannot
speak to those details about the participants.
Respondents were asked, “Do you believe that transgender people deserve the same rights
and protections as others in your country?” which is a question that was adapted from a ques-
tion used for a US national poll [78]. Although this question cannot elicit specific details about
a persons’ beliefs about medical interventions, beliefs about transgender identification, or their
beliefs about their own child, it can be used to assess if the participants in this study are similar
in their basic beliefs about the rights of transgender people to the participants in the US
national poll. The majority (88.2%) of the study participants gave affirmative answers to the
question which is consistent with the 89% affirmative response reported in a US national poll
[78]. All self-reported results have the potential limitation of social desirability bias. However,
comparing this self-report sample to the national self-report sample [78], the results show sim-
ilar rates of support. Therefore, there is no evidence that the study sample is appreciably differ-
ent in their support of the rights of transgender people than the general American population.
Rapid-onset gender dysphoria in adolescents and young adults
PLOS ONE | https://doi.org/10.1371/journal.pone.0202330 August 16, 2018 38 / 44
It is also important to note that recruitment was not limited to the websites where the informa-
tion about the study was first posted. Snowball sampling was also used so that any person view-
ing the recruitment information was encouraged to share the information with any person or
community where they thought there could be potentially eligible participants, thus substan-
tially widening the reach of potential respondents. In follow up studies on this topic, an even
wider variety of recruitment sources should be attempted.
Another limitation of this study is that it included only parental perspective. Ideally, data
would be obtained from both the parent and the child and the absence of either perspective
paints an incomplete account of events. Input from the youth would have yielded additional
information. Further research that includes data collection from both parent and child is
required to fully understand this condition. However, because this research has been produced
in a climate where the input from parents is often neglected in the evaluation and treatment of
gender dysphoric AYAs, this research supplies a valuable, previously missing piece to the jig-
saw puzzle. If Hypothesis 3 is correct that for some AYAs gender dysphoria represents an ego-
syntonic maladaptive coping mechanism, data from parents are especially important because
affected AYAs may be so committed to the maladaptive coping mechanism that their ability to
assess their own situation may be impaired. Furthermore, parents uniquely can provide details
of their child’s early development and the presence or absence of readily observable childhood
indicators of gender dysphoria are especially relevant to the diagnosis. There are, however,
obvious limitations to relying solely on parent report. It is possible that some of the participat-
ing parents may not have noticed symptoms of gender dysphoria before their AYA’s disclosure
of a transgender identity; could have been experiencing shock, grief, or difficulty coping from
the disclosure; or even could have chosen to deny or obscure knowledge of long term gender
dysphoria. Readers should hold this possibility in mind. Overall, the 200 plus responses appear
to have been prepared carefully and were rich in detail, suggesting they were written in good
faith and that parents were attentive observers of their children’s lives. Although this research
adds the necessary component of parent observation to our understanding of gender dys-
phoric adolescents and young adults, future study in this area should include both parent and
child input.
This research does not imply that no AYAs who become transgender-identified during
their adolescent or young adult years had earlier symptoms nor does it imply that no AYAs
would ultimately benefit from transition. Rather, the findings suggest that not all AYAs pre-
senting at these vulnerable ages are correct in their self-assessment of the cause of their symp-
toms and some AYAs may be employing a drive to transition as a maladaptive coping
mechanism. It may be difficult to distinguish if an AYA’s declining mental health is occurring
due to the use of a maladaptive coping mechanism, due to the worsening of a pre-existing (or
onset of a new) psychiatric condition, or due to conflict with parents. Clinicians should care-
fully explore these options and try to clarify areas of disagreement with confirmation from out-
side sources such as medical records, psychiatrists, psychologists, primary care physicians, and
other third party informants where possible. Further study of maladaptive coping mecha-
nisms, psychiatric conditions and family dynamics in the context of gender dysphoria and
mental health would be an especially valuable contribution to better understand how to treat
youth with gender dysphoria.
More research is needed to determine the incidence, prevalence, persistence and desistence
rates, and the duration of gender dysphoria for adolescent-onset gender dysphoria and to
examine whether rapid-onset gender dysphoria is a distinct and/or clinically valid subcategory
of gender dysphoria. Adolescent-onset gender dysphoria is sufficiently different from early-
onset of gender dysphoria that persists or worsens at puberty and therefore, the research
results from early-onset gender dysphoria should not be considered generalizable to
Rapid-onset gender dysphoria in adolescents and young adults
PLOS ONE | https://doi.org/10.1371/journal.pone.0202330 August 16, 2018 39 / 44
adolescent-onset gender dysphoria. It is currently unknown whether the gender dysphorias of
adolescent-onset gender dysphoria and of late-onset gender dysphoria occurring in young
adults are transient, temporary or likely to be long-term. Without the knowledge of whether
the gender dysphoria is likely to be temporary, extreme caution should be applied before con-
sidering the use of treatments that have permanent effects such as cross-sex hormones and sur-
gery. Research needs to be done to determine if affirming a newly declared gender identity,
social transition, puberty suppression and cross-sex hormones can cause an iatrogenic persis-
tence of gender dysphoria in individuals who would have had their gender dysphoria resolve
on its own and whether these interventions prolong the duration of time that an individual
feels gender dysphoric before desisting. There is also a need to discover how to diagnose these
conditions, how to treat the AYAs affected, and how best to support AYAs and their families.
Additionally, analyses of online content for pro-transition sites and social media should be
conducted in the same way that content analysis has been performed for pro-eating disorder
websites and social media content [44]. Finally, further exploration is needed for potential con-
tributors to recent demographic changes including the substantial increase in the number of
adolescent natal females with gender dysphoria and the new phenomenon of natal females
experiencing late-onset or adolescent-onset gender dysphoria.
Conclusion
Collecting data from parents in this descriptive exploratory study has provided valuable,
detailed information that allows for the generation of hypotheses about potential factors con-
tributing to the onset and expression of gender dysphoria among AYAs. Emerging hypotheses
include the possibility of a potential new subcategory of gender dysphoria (referred to as
rapid-onset gender dysphoria) that has not yet been clinically validated and the possibility of
social influences and maladaptive coping mechanisms contributing to the development of gen-
der dysphoria. Parent-child conflict may also contribute to the course of the dysphoria. More
research that includes data collection from AYAs, parents, clinicians and third party infor-
mants is needed to further explore the roles of social influence, maladaptive coping mecha-
nisms, parental approaches, and family dynamics in the development and duration of gender
dysphoria in adolescents and young adults.
Supporting information
S1 Appendix. Survey instrument.
(PDF)
S2 Appendix. COREQ checklist.
(PDF)
Acknowledgments
I would like to acknowledge Michael L. Littman, PhD, for his assistance in the statistical analy-
sis of quantitative data, Michele Moore, PhD, for her assistance in qualitative data analysis and
feedback on an earlier version of the manuscript, Lisa Marchiano, LCSW, for feedback on ear-
lier versions of the manuscript, and four external peer-reviewers, three PLOS ONE staff editors
and two Academic Editors for their attention to this research.
Author Contributions
Conceptualization: Lisa Littman.
Rapid-onset gender dysphoria in adolescents and young adults
PLOS ONE | https://doi.org/10.1371/journal.pone.0202330 August 16, 2018 40 / 44
Data curation: Lisa Littman.
Formal analysis: Lisa Littman.
Investigation: Lisa Littman.
Methodology: Lisa Littman.
Project administration: Lisa Littman.
Writing – original draft: Lisa Littman.
Writing – review & editing: Lisa Littman.
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