In the DSM-5, the standard classification of mental disorders used by mental health professionals, this condition is known as “gender dysphoria.” Note that classifying gender dysphoria as a disorder does not—indeed, should not—imply a moral judgment of transgender individuals. Depending on the degree of social stigma associated with it, transgender identity can be accompanied by very significant distress. The point of the mental-health outlook is to help reduce stigma and assist transgender individuals in leading good lives. The role of social norms in this picture, however, remains unclear and hotly debated.

The historical and cross-cultural record indicates that conditions akin to what we now call “transgender identity” have been known to occur in all societies, with varying degrees of acceptance, suppression, or even encouragement. The widespread acceptance of individuals who were born males and dress and live as females, such as the hijra in India, katoey in Thailand, bakla in the Philippines, and travesti in Brazil, for example, long predates the current transgender movement in the West.  Despite a longstanding recognition of their existence, transgender individuals in those countries continue to face some discrimination. Among the Kuna (also known as Guna) of the San Blas Islands in Panama, transgender identity appears to have been fully accepted since precolonial times. As a rare example of a matriarchal and matrilineal society, names and properties are typically passed on from female to female among the Kuna, leading to a cultural preference for having girl children. In this context, male children were sometimes raised as girls, thereby conferring families with a distinct social advantage. This gave rise to a rare example of absence of cultural stigma around transgender identities.

These examples are telling because they point to the importance of different social norms in mediating gendered preferences and behavior. They also introduce another piece in our puzzle: all the culturally recognized incidences of pre-modern transgender individuals mentioned above involve natal males who transition to female. In the DSM-5, prevalence rates of gender dysphoria are estimated at 0.005 percent to 0.014 percent of the population for natal males, and 0.002 percent to 0.003 percent for natal females. The higher prevalence of males exhibiting the condition is likely related to a higher percentage of male homosexuals worldwide (3 to 4 percent) as compared to lesbians (1 to 2 percent). While these rates are the subject of debate, the higher ratio of male homosexuals as compared to women is a consistent finding across surveys.

As attested by current controversies, rates of transgender identity appear to be on the rise, particularly among young people. Increased social acceptance of a previously stigmatized condition likely plays a role in this process, but other findings are clearly puzzling: Transgender identity is now reported among young natal females at rates that clearly exceed all known statistics to date.

In a recent survey of 250 families whose children developed symptoms of gender dysphoria during or right after puberty, Lisa Littman, a physician and professor of behavioral science at Brown University, found that over 80 percent of the youth in her sample were female at birth. Littman’s study reported many other surprising findings. To meet the diagnostic criteria for gender dysphoria, a child typically needs to have shown observable characteristics of the condition prior to puberty, such as “a strong rejection of typically feminine or masculine toys,” or “a strong resistance to wearing typically feminine or masculine clothes.” Again, 80 percent of the parents in the study reported observing none of these early signs in their children.

The plot thickens again: First, many of the youth in the survey had been directly exposed to one or more peers who had recently “come out” as trans. Next, 63.5 percent of the parents reported that in the time just before announcing they were trans, their child had exhibited a marked increase in Internet and social media consumption. Following popular YouTubers who discussed their transition thus emerged as a common factor in many of the cases. After the youth came out, an increase in distress, conflict with parents, and voiced antagonism toward heterosexual people and non-transgender people (known as “cis” or “cisgender”) was also frequently reported. This animosity was also described as extending to “males, white people, gay and lesbian (non-transgender) people.” The view adopted by trans youth, as summed up by one parent, seemed to be that:

“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.”

Parents further reported being derogatorily called “breeders” by their children, or being routinely harassed by children who played “pronoun-police.” The observation that they no longer recognized their child’s voice came up time and again in parental reports. In turn, the eerie similarity between the youth’s discourse and trans-positive online content was repeatedly emphasized. Youth were described as “sounding scripted,” “reading from a script,” “wooden,” “like a form letter,” “verbatim,” “word for word,” or “practically copy and paste.”

Littman raises cautions about encouraging young people’s desire to transition in all instances.  From the cases reviewed in her study, she concluded that what she terms “rapid-onset gender dysphoria” (ROGD) appears to be a novel condition that emerges from cohort and contagion effects and novel social pressures. From this perspective, ROSD likely exhibits an aetiology and epidemiology that is distinct from the “classical” cases of gender dysphoria documented in the DSM.

Littman hypothesizes that ROGD can be cast as a maladaptive coping mechanism for other underlying mental health issues such as trauma or social maladjustment, but also for other exceptional traits like high IQ and giftedness. The peer support, prestige, and identity leveraged by the youth who proudly come out as trans certainly appears to be protective in their circles. As Littman’s study shows, this social signaling strategy also comes with strong disadvantages, particularly as it increases conflict between trans youth and the “cis” majority of the population, which, tellingly, includes a majority of the LGBT community.

The notion reported by parents that the ROGD appears to be “scripted” is also telling. Medical anthropologists describe the process of outsourcing negative feelings to cultural narratives and systems of beliefs as “idioms of distress.” These beliefs can be partially grounded in science and biology (as is the case with current brain-based mental health culture), or not at all (as is the case in cultures that explain mental illness through the idiom of spirit possession). When extreme forms of distress and coping arise through novel social pressures and spread through implicit imitation, strange epidemics of “mass psychogenic illnesses” have been documented. These have extended to dancing plagues, possession epidemics on factory floors, fugue states, or epidemics of face-twitching. These conditions are described as “psychogenic” (originating in the mind) when no underlying physical cause can be determined. But the term “sociogenic,” which highlights the social context in which these conditions occur,  is a better description.

Risk factors for proneness to mass sociogenic illness remain hotly debated. Tellingly, for our investigation, it is broadly recognized that females, perhaps due to their higher sensitivity to social cues on average, are overwhelmingly more prone to such phenomena. Once more, this should not be read as a moral story. Medical sociologist Robert Bartholomew, one of the world’s leading experts on mass sociogenic epidemics, has long argued that phenomena that are still unjustly termed “mass hysteria” should be renamed “collective stress responses.”

It is clear from Littman’s study that the rise of rapid-onset gender dysphoria, which seems to predominantly involve natal females, points to a complex web of social pressures, changing cultural norms, and new modes of distress and coping that warrant further investigation. For parents, educators, and clinicians alike, caution is warranted in dealing with this growing phenomenon.

* Note: An earlier version of this post used the term “transgenderism” which, while often used to describe transgender individuals, is now considered out of date and stigmatizing by many in the LGBT community. “Transgender identity” is the community’s preferred term.  The author thanks the Human Rights Campaign for pointing this out.

*** Note 2: I have received numerous private comments from readers about this article. Some readers pointed out that I did not mention the controversy and significant public backlash that ensued after the study was first published in August 2018. You can read my discussion of this backlash in this next post.

*** Note 3: You may also read my third post, in which I call for dialogue (not debate) and compassion between the different sides of the ROGD debate.