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Littman 2018 ROGD study

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Lisa Littman's 2018 study on Rapid Onset Gender Dysphoria (ROGD)[1] was the first study conducted on the possibility of transgenderism spreading socially. It has several major flaws and has been widely discredited by the scientific community. Despite the problems with the study, it has been cited by TERFS to argue that trans people have a social contagion or that trans people are delusional, or more mildly to say that ROGD only explains the rise in gender dysphoria cases among teens (though can't explain all cases of gender dysphoria).

What does the study say?[edit]

Littman's study aimed to get insight into the lives of trans kids and teens, mainly those who had consumed LGBT-affirming media or had LGBT friends shortly before they rapidly developed gender dysphoria and came out to their parents as transgender. The author collected this data in order to prove her Rapid Onset Gender Dysphoria hypothesis for transgenderism. She posted a 90-question online survey on three websites (4thwavenow, transgendertrend, and youthtranscriticalprofessionals) to reach out to parents of those kids and learn about their kids' situation. The survey was also posted onto a Facebook group called "Parents of Transgender Children" without Littman's knowledge. After getting 256 survey responses, she found that most parents reported their kids engaging with online LGBT content and/or having LGBT friends before coming out as trans. She also noted that after coming out as trans, those kids tended to spend more time online and less time with the family, as well as see a decline in mental health. Littman argued that these trans kids may have developed gender dysphoria due to environmental factors (like their friends and the media they engaged with), and suggested that the scientific field had overlooked these ideas and should give those ideas more weight.

So, what's wrong with the study?[edit]

Just to note at the outset, this study has gone through rebuttal after rebuttal after rebuttal.[2][3][4][5][6] The study has been discredited by the scientific community at large and is sometimes used as an example of bad science in action.

Biased sample[edit]

When it comes to studies about a certain group of people — in this case, trans kids (or the parents of trans kids, which this study chose to look at) — you'll generally want a representative sample of the population you're dealing with. If the sample you're looking at resembles the broader group that you want to learn about, there's less of a chance that the sample group's data will differ from what you would have gotten from the larger group. However, when Littman collected data, she looked exclusively to websites that were biased against affirming the identities of trans kids — mainly 4thwavenow, transgendertrend, and youthtranscriticalprofessionals.[7][note 1] Parents who frequent these sites will have already been conditioned to doubt their kids’ trans identity, so they'll be much more likely to subscribe to ROGD as a justification for their beliefs. She didn't collect data from a representative sample of parents of trans kids, but instead got a representative sample of parents of trans kids who also doubt their kids' identity. This skews the study data, just as reaching out to antivax websites would skew data on how people perceive the connection between vaccines and autism.

On top of this, the study specifically targeted parents who would fit the ROGD hypothesis, reaching out to “parents of teens who became convinced they were the opposite sex after a steady diet of social media and/or peer influence”.[8] At this point, our sample isn't even representative of parents of trans kids who also doubt their kids' identity; it's instead a representative sample of parents of trans kids who also doubt their kids' identity and whose kids meet the basic superficial[note 2] requirements for ROGD to be validated. This sample was probably intentionally recruited to prove that ROGD is a big thing, or at the very least to prove that some gender dysphoria is a social contagion.

It also doesn’t help that the social contagion theory first surfaced via these specific websites[9] (though Littman popularized the term “Rapid Onset Gender Dysphoria”) and not from previous scientific inquiry (though Littman’s study was the first one ever on ROGD), which further suggests that these specific websites were hand-picked by Littman to prove a specific hypothesis.

Polling parents, not children[edit]

Does the author have any personal experience working with transgender youth? I ask, because for those of us with significant experience working with this population (and contrary to the article, very much in alignment with the current literature out there on gender dysphoria et. al.) know that often parents describe their child's disclosure after puberty as coming completely out of the blue, influenced by social media, etc. This has even been described by parents of one kid who literally came out as transgender at age 6, again at age 9 and again at age 13. "this came out of nowhere!" they said. To rely only on parent report, particularly parent reports gathered from websites that exist because of skepticism about transgender identities seems methodologically flawed.
—Someone who, unlike Littman, actually has experience in the field[10]

While polling parents isn’t always a bad thing, it really undermines this particular study for a number of reasons:

  • Parent evaluations and child self-evaluations tend to differ substantially when it comes to mental health, and the difference grows when the parents are stressed about it.[11] Parents of trans kids who frequent websites about a “transgender craze” are probably going to be really stressed because they’ll think their kid is involved in this craze, and that it'll ruin their kid's life down the road.
  • What appears to a parent to be a “rapid” onset may not have been rapid for their child at all, as closeted LGBTQ children tend to stay closeted for a while before coming out (they still fear discrimination/rejection by their family, among other things) and during this time they’ll get a better sense of their gender identity or sexual orientation. When a gay or trans person comes out of the closet to their parents, what the kids had to process over the course of months or years is processed by parents over the course of a few days, and they have to process everything at once — so what looks like a rapid change to parents could be anything but rapid to trans children. This means that the study design is unable to prove that there was any rapid-onset in play with the gender dysphoria in the first place.
  • Even if we are dealing with a situation which is genuinely rapid-onset (not just from the parent’s view but also from the child’s) this isn’t necessarily a bad thing. To quote from Julia Serano: “There is nothing inherently erroneous or illegitimate about a “rapid” onset of gender dysphoria — some trans people experience an epiphany during which all the clues and puzzle pieces suddenly come together, and they finally realize that they are transgender.”[12]
  • 8.6% of the parents sampled, nearly a tenth of the sample, said that they didn't even know if their kids still identified as transgender. This further casts doubt on the ability of those parents to know what's going on in the minds of the kids. If the study is meant to survey parents of trans kids and some of the parents don't even know if their kids are trans, how reliable are the results of that survey when it comes to parents of trans kids? What are the parents thinking when they sign up for a survey like this in the first place? If they don't know because they lost contact with the kid, how reliable are they as a source to report on the kid's current status at all?

Other problems[edit]

In the study, Littman misapplies the DSM-5 in a number of ways. For one, she simplified and dumbed-down the DSM criteria for gender dysphoria so that parents could more easily use those criteria.[5] This could be really problematic because important details could have been removed from Littman's dumbed-down version of the criteria, though we can't know for sure how things changed because Littman doesn't present the modified criteria in her study.[13] What we can know for sure is that the parents didn't have the formal training necessary to diagnose using the DSM's criteria in the first place, which is another way in which Littman misapplied the DSM. Quoting from Arjee Restar, who published a formal critique of Littman's study:

Part of the DSM-5’s diagnostic measurement for gender dysphoria also requires an evaluation of its association with clinically significant distress (American Psychiatric Association, 2013). Unless parents in this paper received formal training and have licenses to conduct clinical psychiatric diagnoses, parents enrolled were not qualified to classify any persons, including their children’s gender dysphoria. Gender dysphoria involves a formalized evaluation that has physical and psychological components, both of which are not easily observable unless one is formally trained (Coleman et al., 2012). As such, relying on parental-respondents’ accounts introduces a significant bias that affects their ability to “diagnose.”[5]

Littman also didn't have much experience in the subject of trans issues specifically, this having been her first study about them and her past studies having been on abortion.[14] While this doesn't mean she can't publish a good study on trans issues, it does show her lack of experience with the subject in the first place, and that lack of experience probably contributed to the poor design of the study.

It's also troubling that despite having her study extensively critiqued at multiple points in time before it was published, she did very little to actually address those criticisms. As the Gender Dysphoria Affirmative Working Group notes,

There are many reports that when Littman presented her preliminary results, she was given extensive critique on the poor scientific quality of her research. She made no attempts to address these issues in her final paper, again suggesting she placed ideology over scientific rigor. Some members of Gender Dysphoria Affirmative Working Group personally attended those sessions, and we have spoken to others with the same experience.
—Gender Dysphoria Affirmative Working Group[15]

In the study, Littman at one point pulls from a few Reddit and Tumblr posts while discussing the possibility of social media spreading transness as a social contagion. The posts she chose paint a picture of the online trans community being toxic and even cultish, as though they're pushing young people to make their transgender identity more important than anything else.[16] However, the surrounding context of these posts shows that Littman cherrypicked certain bits to paint the online trans community in a bad light,[17] which further calls into question her ideological motive in making the study.

It's also worth noting the lack of a control group in the study. We don't get to compare the experiences of these ROGD parents to the experiences of parents whose kids don't appear to fit the parameters of ROGD. If there was a control group, we would be able to more aptly find differences in behavior between the kids who appeared to fit ROGD and those who didn't - and any differences or lack thereof would have given us a clearer perspective on the exact situation of the ROGD-appearing kids.

It's a bad study, but…[edit]

It proves there's a biased, leftist academia![edit]

See the main article on this topic: Political beliefs of academics

Some people will dodge around the actual problems with the study and instead focus on the outrage to the study. They'll argue that the amount of criticism of the study basically amounts to politically-motivated censorship, meant to favor the trans lobby and leftist ideology. Never mind that criticizing a study isn’t the same as trying to censor it.[18] This position allows them to change the topic from the actual merits/impact of the study over to free speech, a more defensible approach taken by conservative networks like Fox News,[19] Breitbart,[20] The Daily Wire,[21] and so on.

There's a problem with that view, though. Yes, there was plenty of public outrage and indeed, many activists and public figures calling for the study to be taken down, but this doesn't reflect the actions of the academic community. The academics didn't censor the study to push leftism - in fact, the study was never even pulled from the journal it was published in. It's still there and available in full.[1] Keep in mind that it's not uncommon for bad studies with many critiques to get retracted from the journals they were published in, but all that the Littman study got was a republishing with some minor changes, alongside a formal comment being linked with it - in fact, some people considered that a victory against censorship, because the data and conclusions of the study went basically unchanged![22]

As for the Brown University press release on the study, it was retracted not due to a political agenda but because of concerns raised about the study quality and design. Brown University made this clear in an update regarding the press release where they said the following:

This is about academic standards. Brown can publicize only a small subset of the great research conducted by our faculty. As a research institution, we feel we must ensure that work that is featured on the University website conforms to the highest academic standards. Given the concerns raised about research design and methods, the most responsible course of action was to stop publicizing the work published in this particular instance. We would have done this regardless of the topic of the article.
—Brown University in a press release[23]

If a press release (that is, not the actual study) about a badly designed study is taken down because of reasons about academic integrity, taking it down wasn't a politically-motivated act. Taking it down was instead an act of academic integrity. Brown University further clarified this in an op-ed on their university newspaper, The Brown Daily Herald:

In this age of “tweet first, ask questions later,” it has been assumed (without evidence) that the University “succumbed to political pressure.” In truth, the decision to cease publicity for the article instead reflects the value the University places on research standards and was not a response to any pressure from people unhappy with the content of the study. Neither has the University in any way censored the research, as some in the media have claimed. The article is still available on the PLOS ONE website and on the author’s Researchers@Brown page, which is maintained by the University.[24]

Regardless, there’s been a good amount of debate in the academic community on the merits of Littman’s study and what to do going forward. Alongside the critiques of the study, there have been a few people who have come out to defend the study.[25] These people have in turn gotten responses,[26][27] as is the case with scientific debate. Littman herself has also published a response to a critique of her study[28] (though it basically amounted to "my study isn't the only one that's bad"). On top of this, Littman's study also has prompted some academics to come out and say that more research should be done on ROGD to learn about its possible implications for the field,[29] which is not what you would expect from an activist academia which wants to shut down unorthodox ideas.

It still proves social contagion anyway![edit]

Some people will still go along with the data (in spite of it being badly collected and clearly unreliable) and argue that because the data found kids having trans friends and consuming trans media before coming out, that must mean that the transness spread from one trans kid to another, or from the media to the kid. This is a case of conflating correlation with causation, as they assume that one led to the other when there are other viable explanations for the correlation.

You could just as easily argue that the situation is actually flipped, and that the kid was closeted and sought out trans people/media, rather than vice versa. Marginalized groups of people tend to seek out one another to get advice or feel comforted by someone whose experiences they can relate to. This would also apply to a trans kid who is closeted (in which case the parents wouldn’t know their kid was trans until the kid comes out as trans). In fact, it’s well documented that gay people reach out to gay communities for help coming out of the closet, as it is for people of various political ideologies when they deal with coming out to their loved ones (most commonly a conservative coming out to their liberal family or vice versa). This same process happens with trans people and trans communities.

Littman herself re-affirms that the study can't decisively prove causation. In a press release that was published within a week of the study, she said that "Descriptive studies aren't randomized controlled trials -- you can't tell cause and effect, and you can't tell prevalence. It's going to take more studies to bring in more information, but this is a start."[30] In many ways Littman intended for her study to be a jumping-off point for future research, not a decisive be-all end-all piece of work.

On the other hand, these correlations were to be expected in the first place - after all, the study did reach out to recruit “parents of teens who became convinced they were the opposite sex after a steady diet of social media and/or peer influence”.[8] How profound or unexpected are the results of a study if you set out to get those exact results in the first place?

...and the social contagion is an epidemic![edit]

Given the above analysis, it's pretty obvious that the study can't prove that there was any social contagion at play. For the sake of the hypothetical, though, let's say that actually there is a social contagion at play and that the study gave accurate real-world descriptions about ROGD. Even then, the data can't be used to determine the prevalence of ROGD, which means you can't use it to say "there's an ROGD epidemic!" and expect the study to support you. The study says this itself:

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.

This should make it pretty clear that anyone saying "this study proves ROGD is an epidemic!!!" hasn't read the study and has no idea what they're talking about.

The assumptions at this point have gotten ridiculous, anyway. We're dismissing all of the earlier listed criticisms of the study and assuming that the study's data is reliable enough to use it for this, and then we're assuming that there is a social contagion at play at all, an assumption which so far is based on no evidence. This is just getting silly now, isn't it?

The sample didn't have an anti-trans bias![edit]

Some people will point out that 86% of the respondents support gay marriage and 88% support trans people having the same rights as other people,[31] so as to shield the parents from accusations of bigotry/bias. There are some problems with this, though. First, let's take a look at the specific questions asked:

Parent attitude on allowing gay and lesbian couples to marry legally[31]

  • Favor (85.9%)
  • Oppose (7.4%)
  • Don’t know (6.6%)

Parent belief that transgender people deserve the same rights and protections as others[31]

  • Yes (88.2%)
  • No (3.1%)
  • Don’t know (7.8%)
  • Other (0.8%)

Let's start with the question about gay marriage. It should be pretty easy to recognize that someone can support gay marriage while not supporting transgender people. This is a position which plenty of TERFs take (and there's plenty of TERFs on the websites Littman chose), as well as an increasing number of Americans (now that gay marriage has become widely accepted in America while trans issues remain divisive). LGB people also differ from trans people in a number of ways, e.g. sexual orientation vs gender identity, the need for medical intervention, etc. With this in mind, it's easier to understand how Littman's gay marriage supporters could also be unsupportive of trans people.

The second question isn't very useful either, as it's really just asking if trans people should have the same basic human, legal, etc. rights and protections as any other person. As it turns out, denying trans people basic universal human rights isn't just typical transphobia, it's an extreme, overtly dehumanizing kind in which trans people simply aren't treated as people (as opposed to the normal kind, which usually is just about treating trans people as delusional or misguided, but still human). To use that question as a catch-all for any and all transphobia is dumb because it really only catches the most extreme transphobia.

A pro-trans Facebook group was also surveyed![edit]

Some people will defend the study by saying that not all of the sample was biased against trans people, because the survey was shared to a private Facebook group called "Parents of Transgender Children" without Littman's knowledge. This Facebook group takes a pro-gender-affirming stance, which stands in opposition to the anti-affirming stance of 4thwavenow, transgendertrend, and youthtranscriticalprofessionals. These people argue that with the Facebook group's size at over 8,000 people, it was big enough to skew the results so that there's a variety of viewpoints involved in the survey, maybe even to the point of balancing out the anti-affirming websites.

Littman intended for the survey to be spread beyond the three websites she originally posted on,[32] but she didn't track where respondents encountered the survey, so we don't know for sure how many of the responses came from the Facebook group.[33] However, we can make reasonable guesses based on the data we already have. In order to figure out how many respondents are affirming towards their kid's gender identity (the distinguishing factor between the Facebook group and the other websites), we can look to a specific question Littman asked in the survey: whether the parents think their kid is correct in their belief of being transgender.

Responses for "Parent thinks their child is correct in their child's belief of being transgender"[34]

  • Yes (2.4%)
  • No (76.5%)
  • Don't know (14.9%)
  • Other (6.3%)

Assuming the Facebook group was predominately made up of "Yes" and "Don't know" responses (as they generally take a gender affirming approach), the responses from there would probably make up 17.3% of the responses at most. This is nowhere near high enough to balance out the other respondents, and this is assuming that every single "Yes" and "Don't know" response came from that group - which is pretty unlikely.

Even if it is the case that the Facebook group gave the survey enough responses to balance out everything, it's still worth noting that this only accounts for one of many problems with the study overall. It'd still be a very flawed study with pretty limited use.

How could the study be improved?[edit]

Most of the content in this section is adapted from Angelo Costa's critique of Littman's study.[35]

One of the most important things to do would be to directly include the kids in the study. This doesn't even mean excluding the parents, as we can survey both the kids and parents. Hearing both sides would give us more context and detail about the kid's situation (we're hearing from multiple sources rather than just one) and by comparing the parent and kid in their response, it can be easier for us to identify bias from either person. This would have quickly dealt with the study's two main critiques - the biased sample and the fact that kids were excluded from the survey.

Another way to improve things would be to contact the clinicians of the kids, who are more experienced in identifying gender dysphoria and just in general have experience working with transgender youth. This would allow for a more accurate diagnosis of gender dysphoria, as you'd now have someone with expertise doing this rather than parents diagnosing based on a dumbed-down version of the DSM-5. The clinician has a much better idea of what to look for when making the diagnosis, and if something seems off to the clinician, they would be able to explain what seemed off with more reliability as the clinician has worked with other trans youth in the past and has that past experience to compare with the kids in the study.

If we wanted to, we could just take out the clinician and interview both kids who allegedly have ROGD and kids who don't, and ask them questions about how they came to their identity, the media they consume, etc. It's worth emphasizing that having an ROGD group in addition to a non-ROGD group can help in that you now have a control group with which to compare to the ROGD group. Even without the clinician, you can still make meaningful comparisons between these two groups and see if any major differences in media consumption, peer influence, and so on.

Academic response[edit]

Nearly all of the relevant scientific community denounced the study as flawed and potentially harmful to the transgender community, the few defenses of the study[25] being met with responses.[26][27] The evidence provided in Littman's study was not adequate for a new, rapid-onset form of gender dysphoria to be formally designated.[36] Alongside the dozens of online critiques of the study, at least two critiques were formally published in journals.[35][5] A critique of Littman's study and ROGD as a broader concept received endorsements from 21 experts in trans health.[37]

After the study was first published and got a lot of negative response, PLOS One, where the study had been published, commissioned a team to critique and revise Littman's study. Her study was republished in March of 2019 with minor changes after being assessed by the team.[38]

Some academics have suggested doing further research into ROGD, noting how little research has been done into it and how it could have implications for the field.[29] This stance was repeated by Angelo Costa, one of the academics to publish a formal critique of Littman's study: "These developmental complexities are often neglected and deserve further investigation. Data such as those collected by Dr. Littman about parents' views and experiences with youth who show sudden signs of gender dysphoria should be further investigated and documented."[35] Littman has said that she will do more research into ROGD in the future.[30]

Additional resources[edit]

Abigail Shrier's book Irreversible Damage: The Transgender Craze Seducing Our Daughters uses Littman's study as a central part of its narrative, so there are a number of helpful videos which cover both the book and the study.

Notes[edit]

  1. It's worth noting that the study was also shared onto a Facebook group called "Parents of Transgender Children" without Littman's knowledge, but it likely didn't contribute much to the overall response count.
  2. Word choice of "superficial" because we're still dealing with what the parents observed, not what the kid actually went through

References[edit]

  1. 1.0 1.1 Parent reports of adolescents and young adults perceived to show signs of a rapid onset of gender dysphoria by Lisa Littman (August 16, 2018) PLOS One. doi:10.1371/journal.pone.0202330 .
  2. https://www.youtube.com/watch?v=5iGmAMPO3CA
  3. https://juliaserano.medium.com/everything-you-need-to-know-about-rapid-onset-gender-dysphoria-1940b8afdeba
  4. https://psychcentral.com/lib/there-is-no-evidence-that-rapid-onset-gender-dysphoria-exists
  5. 5.0 5.1 5.2 5.3 https://link.springer.com/article/10.1007/s10508-019-1453-2
  6. https://www.advocate.com/commentary/2018/2/20/rapid-onset-gender-dysphoria-biased-junk-science
  7. Excerpt from the study: "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 youthtranscriticalprofessionals)".
  8. 8.0 8.1 https://4thwavenow.com/2016/07/02/rapid-onset-gender-dysphoria-new-study-recruiting-parents/
  9. https://juliaserano.blogspot.com/2019/02/origins-of-social-contagion-and-rapid.html
  10. https://journals.plos.org/plosone/article/comment?id=10.1371/annotation/29cab8db-dca6-419b-a087-5cb83008ac97
  11. see the 4th paragraph https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0212578
  12. https://juliaserano.medium.com/everything-you-need-to-know-about-rapid-onset-gender-dysphoria-1940b8afdeba
  13. https://link.springer.com/article/10.1007/s10508-019-1453-2 "Littman (2018) also asked parents to perform two independent “diagnoses” of their child’s gender dysphoria using the DSM-5 criteria for gender dysphoria in (1) childhood and (2) in adolescence and adulthood (i.e., current age) (American Psychiatric Association, 2013); Littman also noted that the language for these measurements was simplified or adapted for parents. Littman neither provided examples of this simplified version of the DSM-5 nor offered evidence about whether best-practice methods for measure adaptation were used prior to administering the survey."
  14. https://web.archive.org/web/20200822185925if_/https://vivo.brown.edu/display/llittman#Publications
  15. https://www.gdaworkinggroup.com/blog/2018/12/5/psychology-today-response
  16. https://journals.plos.org/plosone/article/figure?id=10.1371/journal.pone.0202330.g001
  17. https://journals.plos.org/plosone/article/comment?id=10.1371/annotation/9775a705-7c82-4824-bb86-360f89511b61
  18. https://slate.com/human-interest/2018/08/rapid-onset-gender-dysphoria-study-criticism-is-not-censorship-its-good-science.html
  19. https://www.foxnews.com/us/brown-u-censors-gender-dysphoria-study-worried-that-findings-might-invalidate-the-perspectives-of-transgender-community
  20. https://www.breitbart.com/tech/2018/08/30/brown-university-censors-gender-dysphoria-study-from-website-after-pressure-campaign/
  21. https://www.dailywire.com/news/brown-university-researcher-released-study-about-ben-shapiro
  22. https://world.wng.org/content/rapid_onset_gender_dysphoria_research_vindicated
  23. https://www.brown.edu/news/2019-03-19/gender
  24. https://www.browndailyherald.com/2018/09/09/paxson-19-locke-18-university-committed-academic-freedom-faculty-support/
  25. 25.0 25.1 https://gdworkinggroup.org/2018/08/27/response-to-julia-seranos-critique-of-lisa-littmans-paper-rapid-onset-gender-dysphoria-in-adolescents-and-young-adults-a-study-of-parental-reports/
  26. 26.0 26.1 https://medium.com/@florence.ashley/a-little-less-conversation-a-little-closer-reading-please-on-dangelo-and-marchiano-s-response-to-10e30e07875d
  27. 27.0 27.1 https://juliaserano.medium.com/rapid-onset-gender-dysphoria-scientific-debate-and-suppressing-speech-fd88a83bcd60
  28. https://link.springer.com/article/10.1007/s10508-020-01631-z
  29. 29.0 29.1 Hutchinson, A., Midgen, M. & Spiliadis, A. In Support of Research Into Rapid-Onset Gender Dysphoria. Arch Sex Behav 49, 79–80 (2020). https://doi.org/10.1007/s10508-019-01517-9
  30. 30.0 30.1 https://www.sciencedaily.com/releases/2018/08/180822150809.htm
  31. 31.0 31.1 31.2 https://journals.plos.org/plosone/article/figure?id=10.1371/journal.pone.0202330.t001
  32. From the study: "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 sampling techniques."
  33. From the correction: "However, announcements about the study included requests to distribute the recruitment information and link, and because information about where the participants encountered the announcement was not collected, it is not known which populations were ultimately reached."
  34. https://journals.plos.org/plosone/article/figure?id=10.1371/journal.pone.0202330.t005
  35. 35.0 35.1 35.2 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6424477/
  36. "The level of evidence produced by the Dr. Littman’s study cannot generate a new diagnostic criterion relative to the time of presentation of the demands of medical and social gender affirmation. Several procedures still need to be adopted to generate a potential new subcategory of gender dysphoria that has not yet been clinically validated. One of these procedures is the assessment of mental health professionals trained according to the World Professional Association for Transgender Health (WPATH) and the American Psychological Association (APA) guidelines, interviewing not just the family, but the youth (longitudinally)." https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6424477/
  37. https://medium.com/@florence.ashley/why-rapid-onset-gender-dysphoria-is-bad-science-f8d25ac40a96 see at the bottom of the article
  38. https://everyone.plos.org/2019/03/19/correcting-the-scientific-record-and-an-apology/