Parent reports of adolescents and young adults perceived to ...

Parents describe that the onset of gender dysphoria seemed to occur in ... Click through the PLOS taxonomy to find articles in your field. BrowseSubjectAreas ? ClickthroughthePLOStaxonomytofindarticlesinyourfield. FormoreinformationaboutPLOSSubjectAreas,click here. Article Authors Metrics Comments MediaCoverage ReaderComments(54) Figures Correction 19Mar2019: Littman L (2019) Correction:Parentreportsofadolescentsandyoungadultsperceivedtoshowsignsofarapidonsetofgenderdysphoria. PLOSONE14(3):e0214157. https://doi.org/10.1371/journal.pone.0214157 View correction Figures Abstract Purpose Inon-lineforums,parentshavereportedthattheirchildrenseemedtoexperienceasuddenorrapidonsetofgenderdysphoria,appearingforthefirsttimeduringpubertyorevenafteritscompletion.Parentsdescribethattheonsetofgenderdysphoriaseemedtooccurinthecontextofbelongingtoapeergroupwhereone,multiple,orevenallofthefriendshavebecomegenderdysphoricandtransgender-identifiedduringthesametimeframe.Parentsalsoreportthattheirchildrenexhibitedanincreaseinsocialmedia/internetusepriortodisclosureofatransgenderidentity.Recently,clinicianshavereportedthatpost-pubertypresentationsofgenderdysphoriainnatalfemalesthatappeartoberapidinonsetisaphenomenonthattheyareseeingmoreandmoreintheirclinic.Academicshaveraisedquestionsabouttheroleofsocialmediainthedevelopmentofgenderdysphoria.Thepurposeofthisstudywastocollectdataaboutparents’observations,experiences,andperspectivesabouttheiradolescentandyoungadult(AYA)childrenshowingsignsofanapparentsuddenorrapidonsetofgenderdysphoriathatbeganduringorafterpuberty,anddevelophypothesesaboutfactorsthatmaycontributetotheonsetand/orexpressionofgenderdysphoriaamongthisdemographicgroup. Methods Forthisdescriptive,exploratorystudy,recruitmentinformationwithalinktoa90-questionsurvey,consistingofmultiple-choice,Likert-typeandopen-endedquestionswasplacedonthreewebsiteswhereparentshadreportedsuddenorrapidonsetsofgenderdysphoriaoccurringintheirteenoryoungadultchildren.Thestudy’seligibilitycriteriaincludedparentalresponsethattheirchildhadasuddenorrapidonsetofgenderdysphoriaandparentalindicationthattheirchild’sgenderdysphoriabeganduringorafterpuberty.Tomaximizethechancesoffindingcasesmeetingeligibilitycriteria,thethreewebsites(4thwavenow,transgendertrend,andyouthtranscriticalprofessionals)wereselectedfortargetedrecruitment.Websitemoderatorsandpotentialparticipantswereencouragedtosharetherecruitmentinformationandlinktothesurveywithanyindividualsorcommunitiesthattheythoughtmightincludeeligibleparticipantstoexpandthereachoftheprojectthroughsnowballsamplingtechniques.DatawerecollectedanonymouslyviaSurveyMonkey.Quantitativefindingsarepresentedasfrequencies,percentages,ranges,meansand/ormedians.Open-endedresponsesfromtwoquestionsweretargetedforqualitativeanalysisofthemes. Results Therewere256parent-completedsurveysthatmetstudycriteria.TheAYAchildrendescribedwerepredominantlynatalfemale(82.8%)withameanageof16.4yearsatthetimeofsurveycompletionandameanageof15.2whentheyannouncedatransgender-identification.Perparentreport,41%oftheAYAshadexpressedanon-heterosexualsexualorientationbeforeidentifyingastransgender.Many(62.5%)oftheAYAshadreportedlybeendiagnosedwithatleastonementalhealthdisorderorneurodevelopmentaldisabilitypriortotheonsetoftheirgenderdysphoria(rangeofthenumberofpre-existingdiagnoses0–7).In36.8%ofthefriendshipgroupsdescribed,parentparticipantsindicatedthatthemajorityofthemembersbecametransgender-identified.ParentsreportedsubjectivedeclinesintheirAYAs’mentalhealth(47.2%)andinparent-childrelationships(57.3%)sincetheAYA“cameout”andthatAYAsexpressedarangeofbehaviorsthatincluded:expressingdistrustofnon-transgenderpeople(22.7%);stoppingspendingtimewithnon-transgenderfriends(25.0%);tryingtoisolatethemselvesfromtheirfamilies(49.4%),andonlytrustinginformationaboutgenderdysphoriafromtransgendersources(46.6%).Most(86.7%)oftheparentsreportedthat,alongwiththesuddenorrapidonsetofgenderdysphoria,theirchildeitherhadanincreaseintheirsocialmedia/internetuse,belongedtoafriendgroupinwhichoneormultiplefriendsbecametransgender-identifiedduringasimilartimeframe,orboth Conclusion Thisdescriptive,exploratorystudyofparentreportsprovidesvaluabledetailedinformationthatallowsforthegenerationofhypothesesaboutfactorsthatmaycontributetotheonsetand/orexpressionofgenderdysphoriaamongAYAs.Emerginghypothesesincludethepossibilityofapotentialnewsubcategoryofgenderdysphoria(referredtoasrapid-onsetgenderdysphoria)thathasnotyetbeenclinicallyvalidatedandthepossibilityofsocialinfluencesandmaladaptivecopingmechanisms.Parent-childconflictmayalsoexplainsomeofthefindings.MoreresearchthatincludesdatacollectionfromAYAs,parents,cliniciansandthirdpartyinformantsisneededtofurtherexploretherolesofsocialinfluence,maladaptivecopingmechanisms,parentalapproaches,andfamilydynamicsinthedevelopmentanddurationofgenderdysphoriainadolescentsandyoungadults. Citation:LittmanL(2018)Parentreportsofadolescentsandyoungadultsperceivedtoshowsignsofarapidonsetofgenderdysphoria.PLoSONE13(8): e0202330. https://doi.org/10.1371/journal.pone.0202330Editor:DanielRomer,UniversityofPennsylvania,UNITEDSTATESReceived:October7,2017;Accepted:August1,2018;Published:August16,2018Copyright:©2018LisaLittman.ThisisanopenaccessarticledistributedunderthetermsoftheCreativeCommonsAttributionLicense,whichpermitsunrestricteduse,distribution,andreproductioninanymedium,providedtheoriginalauthorandsourcearecredited.DataAvailability:Thedatacannotbemadeavailableduetoethicalandregulatoryrestrictions.Thestudyparticipantsdidnotprovideconsenttohavetheirresponsessharedpublicly,sharedinpublicdatabases,orsharedwithoutsideresearchers.TheProgramfortheProtectionofHumanSubjects(PPHS)attheIcahnSchoolofMedicineatMountSinaiisnotpermittingthesharingofdatabeyondwhatisreportedinthepaperowingtothesensitivenatureofthecollectedinformation,thecontextofthestudytopic,itsrelease’spossibleimpactontheparticipants’reputationandstandinginthecommunity,andtheriskofparticipantrecognitionthroughlinkageofdetails.Asparticipants’identifierswerenotcollecteditisnotpossibletocontactparticipantsandaskfortheirconsenttodiscloseatthistime.Foranyquestionsaboutrestrictionondatasharing,pleasecontactPPHSattheIcahnSchoolofMedicineatMountSinai([email protected]).Funding:Theauthorreceivednospecificfundingforthiswork.Competinginterests:LisaLittman,MD,MPH,providespublichealthconsultingontopicsunrelatedtothisresearch.SheisamemberofseveralprofessionalorganizationsincludingtheAmericanCollegeofPreventiveMedicine(ACPM),theAmericanPublicHealthAssociation(APHA),theSocietyforAdolescentHealthandMedicine(SAHM),theSocietyofFamilyPlanning(SFP),theInternationalAcademyofSexResearch(IASR),andtheWorldProfessionalAssociationforTransgenderHealth(WPATH). IntroductionInrecentyears,anumberofparentshavebegunreportinginonlinediscussiongroupssuchas4thwavenowintheUS(https://4thwavenow.com)andTransgenderTrendintheUK(https://www.transgendertrend.com)thattheiradolescentandyoungadult(AYA)children,whohavehadnohistoriesofchildhoodgenderidentityissues,experiencedaperceivedsuddenorrapidonsetofgenderdysphoria.Parentshavedescribedclustersofgenderdysphoriainpre-existingfriendgroupswithmultipleorevenallmembersofafriendgroupbecominggenderdysphoricandtransgender-identifiedinapatternthatseemsstatisticallyunlikelybasedonpreviousresearch[1–8].Parentsdescribeaprocessofimmersioninsocialmedia,suchas“binge-watching”YouTubetransitionvideosandexcessiveuseofTumblr,immediatelyprecedingtheirchildbecominggenderdysphoric[1–2,9].Thesetypesofpresentationshavenotbeendescribedintheresearchliteratureforgenderdysphoria[1–10]andraisethequestionofwhethersocialinfluencesmaybecontributingtoorevendrivingtheseoccurrencesofgenderdysphoriainsomepopulationsofadolescentsandyoungadults.(Note:Theterminologyof“natalsex”,includingtheterms“natalfemale”and“natalmale”,willbeusedthroughoutthisarticle.Natalsexreferstoanindividual’ssexasitwasobservedanddocumentedatthetimeofbirth.Someresearchersalsousetheterminology“assignedatbirth”.) Background Genderdysphoriainadolescents Genderdysphoria(GD)isdefinedasanindividual'spersistentdiscomfortwiththeirbiologicalsexorassignedgender[11].Twotypesofgenderdysphoriastudiedincludeearly-onsetgenderdysphoria,wherethesymptomsofgenderdysphoriabegininearlychildhood,andlate-onsetgenderdysphoria,wherethesymptomsbeginafterpuberty[11].Late-onsetgenderdysphoriathatoccursduringadolescenceisnowcalledadolescent-onsetgenderdysphoria.Themajorityofadolescentswhopresentforcareforgenderdysphoriaareindividualswhoexperiencedearly-onsetgenderdysphoriathatpersistedorworsenedwithpubertyalthoughanatypicalpresentationhasbeendescribedwhereadolescentswhodidnotexperiencechildhoodsymptomspresentwithnewsymptomsinadolescence[7,12].Adolescent-onsetofgenderdysphoriahasonlyrecentlybeenreportedintheliteraturefornatalfemales[5,10,13–14].Infact,priorto2012,therewerelittletonoresearchstudiesaboutadolescentfemaleswithgenderdysphoriafirstbeginninginadolescence[10].Thus,farmoreisknownaboutadolescentswithearly-onsetgenderdysphoriathanadolescentswithadolescent-onsetgenderdysphoria[6,15].Althoughnotallresearchstudiesongenderdysphoricadolescentsexcludethosewithadolescent-onsetgenderdysphoria[10],itisimportanttonotethatmostofthestudiesonadolescents,particularlythoseaboutgenderdysphoriapersistenceanddesistanceratesandoutcomesfortheuseofpubertysuppression,cross-sexhormones,andsurgeryonlyincludedsubjectswhosegenderdysphoriabeganinchildhoodandsubjectswithadolescent-onsetgenderdysphoriawouldnothavemetinclusioncriteriaforthesestudies[16–24].Therefore,mostoftheresearchonadolescentswithgenderdysphoriatodateisnotgeneralizabletoadolescentsexperiencingadolescent-onsetgenderdysphoria[16–24]andtheoutcomesforindividualswithadolescent-onsetgenderdysphoria,includingpersistenceanddesistenceratesandoutcomesfortreatments,arecurrentlyunknown. Asrecentlyas2012,therewereonlytwoclinics(oneinCanadaandoneintheNetherlands)thathadgatheredenoughdatatoprovideempiricalinformationaboutthemainissuesforgenderdysphoricadolescents[25].Bothinstitutionsconcludedthatthemanagementofadolescent-onsetgenderdysphoriaismorecomplicatedthanthemanagementofearly-onsetgenderdysphoriaandthatindividualswithadolescent-onsetaremorelikelytohavesignificantpsychopathology[25].Thepresentationofgenderdysphoriacanoccurinthecontextofseverepsychiatricdisorders,developmentaldifficulties,oraspartoflarge-scaleidentityissuesand,forthesepatients,medicaltransitionmightnotbeadvisable[13].TheAPATaskForceontheTreatmentofGenderIdentityDisordernotesthatadolescentswithgenderdysphoria“shouldbescreenedcarefullytodetecttheemergenceofthedesireforsexreassignmentinthecontextoftraumaaswellasforanydisorder(suchasschizophrenia,mania,psychoticdepression)thatmayproducegenderconfusion.Whenpresent,suchpsychopathologymustbeaddressedandtakenintoaccountpriortoassistingtheadolescent’sdecisionastowhetherornottopursuesexreassignmentoractuallyassistingtheadolescentwiththegendertransition.”[25]. Demographicandclinicalchangesforgenderdysphoria Although,by2013,therewasresearchdocumentingthatasignificantnumberofnatalmalesexperiencedgenderdysphoriathatbeganduringorafterpuberty,therewaslittleinformationaboutthistypeofpresentationfornatalfemales[5].Startinginthemid-2000stherehasbeenasubstantialchangeindemographicsofpatientspresentingforcarewithmostnotablyanincreaseinadolescentfemalesandaninversionofthesexratiofromonefavoringnatalmalestoonefavoringnatalfemales[26–28].Andnow,someclinicianshavenotedthattheyareseeingincreasinglyintheirclinic,thephenomenonofnatalfemalesexpressingapost-pubertyrapidonsetofgenderdysphoria[14].Someresearchershavesuggestedthatincreasedvisibilityoftransgenderpeopleinthemedia,availabilityofinformationonline,withapartialreductionofstigmamayexplainsomeoftheincreasesinnumbersofpatientsseekingcare[27],butthesefactorswouldnotexplainthereversalofthesexratio,disproportionateincreaseinadolescentnatalfemales,andthenewphenomenonofnatalfemalesexperiencinggenderdysphoriathatbeginsduringorafterpuberty.Iftherewereculturalchangesthatmadeitmoreacceptablefornatalfemalestoseektransition[27],thatwouldnotexplainwhythereversalofthesexratioreportedforadolescentshasnotbeenreportedforolderadultpopulations[26].Therearemanyunansweredquestionsaboutpotentialcausesfortherecentdemographicandclinicalchangesforgenderdysphoricindividuals. Socialandpeerinfluences Parentalreports(onsocialmedia)offriendclustersexhibitingsignsofgenderdysphoria[1–4]andincreasedexposuretosocialmedia/internetprecedingachild’sannouncementofatransgenderidentity[1–2,9]raisethepossibilityofsocialandpeerinfluences.Indevelopmentalpsychologyresearch,impactsofpeersandothersocialinfluencesonanindividual’sdevelopmentaresometimesdescribedusingthetermspeercontagionandsocialcontagion,respectively.Theuseof“contagion”inthiscontextisdistinctfromtheterm’suseinthestudyofinfectiousdisease,andfurthermoreitsuseasanestablishedacademicconceptthroughoutthisarticleisnotmeantinanywaytocharacterizethedevelopmentalprocess,outcome,orbehaviorasadiseaseordisease-likestate,ortoconveyanyvaluejudgement.Socialcontagion[29]isthespreadofaffectorbehaviorsthroughapopulation.Peercontagion,inparticular,istheprocesswhereanindividualandpeermutuallyinfluenceeachotherinawaythatpromotesemotionsandbehaviorsthatcanpotentiallyhavenegativeeffectsontheirdevelopment[30].Peercontagionhasbeenassociatedwithdepressivesymptoms,disorderedeating,aggression,bullying,anddruguse[30–31].Internalizingsymptomssuchasdepressioncanbespreadviathemechanismsofco-rumination,whichentailstherepetitivediscussionofproblems,excessivereassuranceseeking(ERS),andnegativefeedback[30,32–34].Deviancytraining,whichwasfirstdescribedforrulebreaking,delinquency,andaggression,istheprocesswherebyattitudesandbehaviorsassociatedwithproblembehaviorsarepromotedwithpositivereinforcementbypeers[35,36]. Peercontagionhasbeenshowntobeafactorinseveralaspectsofeatingdisorders.Thereareexamplesintheeatingdisorderandanorexianervosaliteratureofhowbothinternalizingsymptomsandbehaviorshavebeensharedandspreadviapeerinfluences[37–41]whichmayhaverelevancetoconsiderationsofarapidonsetofgenderdysphoriaoccurringinAYAs.Friendshipcliquescansetthenormsforpreoccupationwithone’sbody,one’sbodyimage,andtechniquesforweightloss,andcanpredictanindividual’sbodyimageconcernsandeatingbehaviors[37–39].Peerinfluenceisintensifiedininpatientandoutpatienttreatmentsettingsforpatientswithanorexiaandcounter-therapeuticsubculturesthatactivelypromotethebeliefsandbehaviorsofanorexianervosahavebeenobserved[39–41].Inthesesettings,thereisagroupdynamicwherethe“best”anorexics(thosewhoarethinnest,mostresistanttogainingweight,andwhohaveexperiencedthemostmedicalcomplicationsfromtheirdisease)areadmired,validated,andseenasauthenticwhilethepatientswhowanttorecoverfromanorexiaandcooperatewithmedicaltreatmentaremaligned,ridiculed,andmarginalized[39–41].Additionally,behaviorsassociatedwithdeceivingparentsanddoctorsabouteatingandweightloss,referredtoasthe“anorexictricks,”aresharedbypatientsinamannerakintodeviancytraining[39–41].Onlineenvironmentsprovideampleopportunityforexcessivereassuranceseeking,co-rumination,positiveandnegativefeedback,anddeviancytrainingfrompeerswhosubscribetounhealthy,self-harmingbehaviors.Thepro-eatingdisordersitesprovidemotivationforextremeweightloss(sometimescallingthemotivationalcontent“thinspiration”)[42–44].Suchsitespromotevalidationofeatingdisorderasanidentity,andoffer“tipsandtricks”forweightlossandfordeceivingparentsanddoctorssothatindividualsmaycontinuetheirweight-lossactivities[42–44].Ifsimilarmechanismsareatworkinthecontextofgenderdysphoria,thisgreatlycomplicatestheevaluationandtreatmentofimpactedAYAs. Inthepastdecade,therehasbeenanincreaseinvisibility,socialmedia,anduser-generatedonlinecontentabouttransgenderissuesandtransition[45],whichmayactasadouble-edgedsword.Ontheonehand,anincreaseinvisibilityhasgivenavoicetoindividualswhowouldhavebeenunder-diagnosedandundertreatedinthepast[45].Ontheotherhand,itisplausiblethatonlinecontentmayencouragevulnerableindividualstobelievethatnonspecificsymptomsandvaguefeelingsshouldbeinterpretedasgenderdysphoriastemmingfromatransgendercondition.Recently,leadinginternationalacademicandclinicalcommentatorshaveraisedthequestionabouttheroleofsocialmediaandonlinecontentinthedevelopmentofgenderdysphoria[46].Concernhasbeenraisedthatadolescentsmaycometobelievethattransitionistheonlysolutiontotheirindividualsituations,thatexposuretointernetcontentthatisuncriticallypositiveabouttransitionmayintensifythesebeliefs,andthatthoseteensmaypressuredoctorsforimmediatemedicaltreatment[25].TherearemanyexamplesonpopularsitessuchasReddit(www.reddit.comwithsubredditask/r/transgender)andTumblr(www.tumblr.com)whereonlineadvicepromotestheideathatnonspecificsymptomsshouldbeconsideredtobegenderdysphoria,conveysanurgencytotransition,andinstructsindividualshowtodeceiveparents,doctors,andtherapiststoobtainhormonesquickly[47].Fig1includesexamplesofonlineadvicefromRedditandTumblr. Download: PPTPowerPointslidePNGlargerimageTIFForiginalimageFig1.ExamplequotesofonlineadvicefromRedditandTumblr. https://doi.org/10.1371/journal.pone.0202330.g001 Purpose Rapidpresentationsofadolescent-onsetgenderdysphoriaoccurringinclustersofpre-existingfriendgroupsarenotconsistentwithcurrentknowledgeaboutgenderdysphoriaandhavenotbeendescribedinthescientificliteraturetodate[1–8].Thepurposeofthisdescriptive,exploratoryresearchisto(1)collectdataaboutparents’observations,experiences,andperspectivesabouttheirAYAchildrenshowingsignsofarapidonsetofgenderdysphoriathatbeganduringorafterpuberty,and(2)develophypothesesaboutfactorsthatmaycontributetotheonsetand/orexpressionofgenderdysphoriaamongthisdemographicgroup. MaterialsandmethodsTheIcahnSchoolofMedicineatMountSinai,ProgramfortheProtectionofHumanSubjectsprovidedapprovalofresearchforthisproject(HS#:16–00744). Participants Duringtherecruitmentperiod,256parentscompletedonlinesurveysthatmetthestudycriteria.Thesampleofparentsincludedmorewomen(91.7%)thanmen(8.3%)andparticipantswerepredominantlybetweentheagesof45and60(66.1%)(Table1).MostrespondentswereWhite(91.4%),non-Hispanic(99.2%),andlivedintheUnitedStates(71.7%).MostrespondentshadaBachelor’sdegree(37.8%)orgraduatedegree(33.1%).Theadolescentsandyoungadults(AYAs)describedbytheirparentswerepredominantlyfemalesexatbirth(82.8%)withanaveragecurrentageof16.4years(range,11–27years).SeeTable2. Download: PPTPowerPointslidePNGlargerimageTIFForiginalimageTable1.Demographicandotherbaselinecharacteristicsofparentrespondents. https://doi.org/10.1371/journal.pone.0202330.t001 Download: PPTPowerPointslidePNGlargerimageTIFForiginalimageTable2.DemographicandotherbaselinecharacteristicsofAYAs. https://doi.org/10.1371/journal.pone.0202330.t002 Procedure A90-questionsurveyinstrumentwithmultiplechoice,Likert-type,andopen-endedquestionswascreatedbytheresearcher.Thesurveywasdesignedforparents(respondents)tocompleteabouttheiradolescentandyoungadultchildren.ThesurveywasuploadedontoSurveyMonkey(SurveyMonkey,PaloAlto,CA,USA)viaanaccountthatwasHIPPA-enabled.IRBapprovalforthestudyfromtheIcahnSchoolofMedicineatMountSinaiinNewYork,NYwasreceived.Recruitmentinformationwithalinktothesurveywasplacedonthreewebsiteswhereparentsandprofessionalshadbeenobservedtodescribewhatseemedtobeasuddenorrapidonsetofgenderdysphoria(4thwavenow,transgendertrend,andyouthtranscriticalprofessionals),althoughthespecificterminology“rapidonsetgenderdysphoria”didnotappearonthesewebsitesuntiltherecruitmentinformationusingthattermwasfirstpostedonthesites.Websitemoderatorsandpotentialparticipantswereencouragedtosharetherecruitmentinformationandlinktothesurveywithanyindividualsorcommunitiesthattheythoughtmightincludeeligibleparticipantstoexpandthereachoftheprojectthroughsnowballsamplingtechniques.ThesurveywasactivefromJune29,2016toOctober12,2016(3.5months)andtook30–60minutestocomplete.Participantscompletedthesurveyatatimeandplaceoftheirownchoosing.DatawerecollectedanonymouslyandstoredsecurelywithSurveyMonkey. Participationinthisstudywasvoluntaryanditspurposewasclearlydescribedintherecruitmentinformation.Electronicconsentwasobtained.Participantshadtheoptiontowithdrawconsentatanytimepriortosubmittingresponses.Inclusioncriteriawere(1)completionofasurveywithparentalresponsethatthechildhadasuddenorrapidonsetofgenderdysphoria;and(2)parentalindicationthatthechild’sgenderdysphoriabeganduringorafterpuberty.Therewaslogicembeddedinthesurveythatdisqualifiedsurveysthatanswered“no”(orskippedthequestion)aboutwhetherthechildhadasuddenorrapidonsetofgenderdysphoriaand23surveysweredisqualifiedpriortocompletion(20“no”answersand3skippedanswers).Aftercleaningthedataforthe274completedsurveys,8surveyswereexcludedfornothavingasuddenorrapidonsetofgenderdysphoriaand10surveyswereexcludedfornothavinggenderdysphoriathatbeganduringorafterpuberty,whichleft256completedsurveysforinclusion.Asthesurveywasvoluntarytherewasnorefusalordropoutrate. Recruitmentsites Therewerefoursitesknowntopostrecruitmentinformationabouttheresearchstudy.Thefirstthreewerepostedduetodirectcommunicationwiththemoderatorsofthesites.Thefourthsitepostedrecruitmentinformationsecondarytothesnowballsamplingtechnique.Thefollowingdescriptionsprovidedetailsaboutthesesites. 4thwavenow 4thwavenowwascreatedin2015.Thesite,asseenindigitallyarchivedscreenshotsfrom2015and2016,statedthatitisa“safeplaceforgender-skepticalparentsandtheirallies”,offeredsupportforparents,andexpressedconcernabouttherushtodiagnoseyoungpeopleastransgenderandtherushtoproceedtomedicaltreatmentforthem[2,48].ByJune2016,thesitehadexpandedtoincludethewritingofseveralparents,“formerlytrans-identifiedpeople,andpeoplewithprofessionalexpertiseandexperiencewithyoungpeoplequestioningtheirgenderidentity”[9].Theperspectiveofthissitemightbedescribedascautiousaboutmedicalandsurgicaltransitionoverall—specificallywithacautiousornegativeviewofmedicalandsurgicalinterventionsforchildren,adolescents,andyoungadultsandanacceptingviewthatmatureadultscanmaketheirowndecisionsabouttransition[2,9]. Transgendertrend TransgendertrendwasfoundedinNovember2015.ThedigitallyarchivedscreenshotsfromNovember2015andJuly2016“WhoAreWe?”sectionincludethefollowingdescription,“WeareaninternationalgroupofparentsbasedmainlyintheUK,USandCanada,whoareconcernedaboutthecurrenttrendtodiagnose‘gendernon-conforming’childrenastransgender.Werejectcurrentconservative,reactionary,religious-fundamentalistviewsaboutsexuality.Wecomefromdiversebackgrounds,somewithexpertiseinchilddevelopmentandpsychology,somewhowerethemselvesextremegendernon-conformingchildrenandadolescents,somewhoseownchildrenhaveself-diagnosedas‘trans’andsomewhoknowsupportivetransadultswhoarealsoquestioningrecenttheoriesof‘transgenderism’”[49].InJulyof2016,therewasadditionaltextadded,expressingconcernaboutlegislationregardingpublicbathroomsandchangingrooms[50]. Youthtranscriticalprofessionals YouthTransCriticalProfessionalswascreatedinMarch2016.ThedigitallyarchivedscreenshotfromtheApril2016“About”sectionstatedthefollowing:“Thiswebsiteisacommunityofprofessionals“thinkingcriticallyabouttheyouthtransgendermovement.Wearepsychologists,socialworkers,doctors,medicalethicists,andacademics.Wetendtobeleft-leaning,open-minded,andpro-gayrights.However,weareconcernedaboutthecurrenttrendtoquicklydiagnoseandaffirmyoungpeopleastransgender,oftensettingthemdownapathtowardmedicaltransition.Ourconcerniswithmedicaltransitionforchildrenandyouth.Wefeelthatunnecessarysurgeriesand/orhormonaltreatmentswhichhavenotbeenprovensafeinthelong-termrepresentsignificantrisksforyoungpeople”[51]. Parentsoftransgenderchildren ParentsofTransgenderChildrenisaprivateFacebookgroupwithmorethan8,000members[52].Thecurrent“About”sectionstatesthatrequeststojointhegroup“willbedeniedifyouarenottheparent(orimmediatecaregiverorfamilymember)ofatransgender,gender-fluid,gender-questioning,agender,orothergender-nonconformingchild(ofanyage);orifyouareuncooperativeduringscreening”andthatthe“groupiscomprisedofparentsandparentingfigures,aswellasaselectgroupofadvocatesINVITEDbytheadmin[istrative]stafftoassist&helpuswithunderstandinglegalandotherconcerns”[52].Althoughtheparentdiscussionsandcommentsarenotviewabletonon-members[52],thisgroupisperceivedtobepro-gender-affirming.TheParentsofTransgenderChildrenFacebookgroupisconsideredtobeasitetofindparentswhoaresupportiveoftheirchild’sgenderidentity[53],anditislistedasaresourceinagenderaffirmingparentingguide[54]andbygenderaffirmingorganizations[55–56]. Measures Basicdemographicandbaselinecharacteristics Basicdemographicandbaselinecharacteristicquestions,includingparentalattitudesaboutLGBTrights,wereincluded.Parentswereaskedabouttheirchildren’smentalhealthdisordersandneurodevelopmentaldisabilitiesthatwerediagnosedbeforetheirchild’sonsetofgenderdysphoriaaswellasduringandafter.Thequestion,“Hasyourchildbeenformallyidentifiedasacademicallygifted,learningdisabled,both,neither?”wasusedasaproxytoestimateratesofacademicgiftednessandlearningdisabilities.Questionsabouttraumaandnon-suicidalself-injurywerealsoincludedaswerequestionsaboutsocialdifficultiesdescribedinapreviousresearchstudyaboutgenderdysphoricadolescents[13]. DSM-5diagnosticcriteriaforgenderdysphoriainchildren TheDSM5criteriaforgenderdysphoriainchildrenconsistofeightindicatorsofgenderdysphoria[57].Tomeetcriteriafordiagnosis,achildmustmanifestatleastsixoutofeightindicatorsincludingtheonedesignatedA1,“Astrongdesiretobetheothergenderoraninsistencethatoneistheothergender(orsomealternativegenderdifferentfromone’sassignedgender).”Threeoftheindicators(A1,A7,andA8)refertodesiresordislikesofthechild.Fiveoftheindicators(A2-A6)arereadilyobservablebehaviorsandpreferencessuchasastrongpreferenceorstrongresistancetowearingcertainkindsofclothing;astrongpreferenceorstrongrejectionofspecifictoys,gamesandactivities;andastrongpreferenceforplaymatesoftheothergender[57].Theeightindicatorsweresimplifiedforlanguageandparentswereaskedtonotewhich,ifany,theirchildhadexhibitedpriortopuberty.Therequirementofsix-monthdurationofsymptomswasnotincluded. DSM-5diagnosticcriteriaforgenderdysphoriainadolescentsandadults TheDSM-5criteriaforgenderdysphoriainadolescentsandadultsconsistofsixindicatorsofgenderdysphoria[57].Tomeetcriteriafordiagnosis,anadolescentoradultmustmanifestatleasttwoofthesixindicators.Thesixindicatorsweresimplifiedforlanguage,thefirstindicatorwasadjustedforaparenttoanswerabouttheirchild,andparentswereaskedtonotewhich,ifany,theirchildwasexpressingcurrently.Therequirementofsix-monthdurationofsymptomswasnotincluded. Exposuretofriendgroupsandsocialmedia/internetcontent SurveyquestionsweredevelopedtodescribeAYAfriendgroups,includingnumberoffriendsthatbecametransgender-identifiedinasimilartimeperiodastheAYA,peergroupdynamicsandbehaviors,andexposuretospecifictypesofsocialmedia/internetcontentandmessagesthathavebeenobservedonsitespopularwithteens,suchasRedditandTumblr. Behaviors,outcomes,clinicalinteractions Surveyquestionsweredevelopedtospecificallyquantifyadolescentbehaviorsthathadbeendescribedbyparentsinonlinediscussionsandobservedelsewhere.Participantswereaskedtodescribeoutcomessuchastheirchild’smentalwell-beingandparent-childrelationshipsincebecomingtransgender-identified.Parentswerealsoaskedaboutexperienceswithcliniciansandtheirchildren’sdispositionregardingstepstakenfortransitionanddurationoftransgender-identificationbothforchildrenwhowerestilltransgender-identifiedandforchildrenwhowerenolongertransgender-identified. Copingwithstrongornegativeemotions TwoquestionsabouttheAYAs’abilitytocopewithnegativeandstrongemotionswereincluded.Onequestionwas“Howdoesyourchildhandlestrongemotions?(pleaseselectthebestanswer).”Offeredanswerswere“Mychildisoverwhelmedbystrongemotionsandgoestogreatlengthstoavoidfeelingthem,”“Mychildisoverwhelmedbystrongemotionsandtriestoavoidfeelingthem,”“Mychildneitheravoidsnotseeksoutstrongemotions,”“Mychildtriestoseekoutsituationsinordertofeelstrongemotions,”“Mychildgoestogreatlengthstoseekoutsituationsinordertofeelstrongemotions,”“Noneoftheabove,”“Idon’tknow.”Theotherquestionwas“Howwouldyourateyourchild’sabilitytodealwiththeirnegativeemotionsandchannelthemintosomethingproductive?”Anexamplewasgivenregardingdealingwithalowtestgradebystudyingharderforthenexttest(excellent)orbyignoringit,throwingatantrum,blamingtheteacherordistractingthemselveswithcomputergames,alcohol,drugs,etc.(extremelypoor).Offeredanswerswere:excellent,good,fair,poor,extremelypoor,andIdon’tknow. DataanalysisStatisticalanalysesofquantitativedatawereperformedusingExcelandcustomshellscripts(Unix).Quantitativefindingsarepresentedasfrequencies,percentages,ranges,meansand/ormedians.ANOVAs,chi-squared,andt-testscomparisonswereusedwhereappropriateusingpubliclyavailablecalculatorsandp<0.05wasconsideredsignificant.Qualitativedatawereobtainedfromopentextanswerstoquestionsthatallowedparticipantstoprovideadditionalinformationorcomments.Thetypesofcommentsanddescriptionswerecategorized,tallied,andreportednumerically.Agroundedtheoryapproachwasselectedastheanalyticstrategyofchoiceforhandlingthequalitativeresponsesbecauseitallowedtheresearchertoassemblethedatainaccordancewiththesalientpointstherespondentsweremakingwithoutforcingthedataintoapreconceivedtheoreticalframeworkoftheresearcher’sownchoosing[58].Illustrativerespondentquotesandsummariesfromthequalitativedataareusedtoillustratethequantitativeresultsandtoproviderelevantexamples.Twoquestionsweretargetedforfullqualitativeanalysisofthemes(onequestiononfriendgroupbehaviorsandoneonclinicianinteractions).Forthesequestions,asecondreviewerwithexpertiseinqualitativemethodswasengaged(MM).Boththeauthor(LL)andreviewer(MM)independentlyanalyzedthecontentoftheopentextanswersandidentifiedmajorthemes.Discrepancieswereresolvedwithcollaborativediscussionandthemeswereexploredandrefineduntilagreementwasreachedforthefinallistsofthemes.RepresentativequotesforeachthemewereselectedbyLL,reviewedbyMM,andagreementwasreached. Results Baselinecharacteristics Baselinecharacteristics(Table1)includedthatthevastmajorityofparentsfavoredgayandlesbiancouples’righttolegallymarry(85.9%)andbelievedthattransgenderindividualsdeservethesamerightsandprotectionsasotherindividualsintheircountry(88.2%).Alongwiththesuddenorrapidonsetofgenderdysphoria,theAYAsbelongedtoafriendgroupwhereoneormultiplefriendsbecamegenderdysphoricandcameoutastransgenderduringasimilartimeastheydid(21.5%),exhibitedanincreaseintheirsocialmedia/internetuse(19.9%),both(45.3%),neither(5.1%),anddon’tknow(8.2%)(Table2).Forcomparisons,thefirstthreecategorieswillbecombinedandcalled“socialinfluence”(86.7%)andthelasttwocombinedas“nosocialinfluence”(13.3%).Nearlyhalf(47.4%)oftheAYAshadbeenformallydiagnosedasacademicallygifted,4.3%hadalearningdisability,10.7%werebothgiftedandlearningdisabled,and37.5%wereneither.SexualorientationasexpressedbytheAYApriortotransgender-identificationislistedseparatelyfornatalfemalesandfornatalmales(Table2).Overall,41%oftheAYAsexpressedanon-heterosexualsexualorientationpriortodisclosingatransgender-identification. ItisimportanttonotethatnoneoftheAYAsdescribedinthisstudywouldhavemetdiagnosticcriteriaforgenderdysphoriainchildhood(Table3).Infact,thevastmajority(80.4%)hadzeroindicatorsfromtheDSM-5diagnosticcriteriaforchildhoodgenderdysphoriawith12.2%possessingoneindicator,3.5%withtwoindicators,and2.4%withthreeindicators.Breakingdowntheseresults,forreadilyobservableindicators(A2-6),83.5%ofAYAshadzeroindicators,10.2%hadoneindicator,3.9%hadtwoindicators,and1.2%hadthreeindicators.Forthedesire/dislikeindicators(A1,A7,A8),whichaparentwouldhaveknowledgeofifthechildexpressedthemverbally,butmightbeunawareifachilddidnot,95.7%hadzeroindicatorsand3.5%hadoneindicator.Parentsrespondedtothequestionaboutwhich,ifany,oftheindicatorsoftheDSMcriteriaforadolescentandadultgenderdysphoriatheirchildwasexperiencingcurrently.Theaveragenumberofpositivecurrentindicatorswas3.5(range0–6)and83.2%oftheAYAsamplewascurrentlyexperiencingtwoormoreindicators.Thus,whilethefocalAYAsdidnotexperiencechildhoodgenderdysphoria,themajorityofthosewhowerethefocusofthisstudywereindeedgenderdysphoricatthetimeofthesurveycompletion. Download: PPTPowerPointslidePNGlargerimageTIFForiginalimageTable3.DSM5Indicatorsforgenderdysphoria. https://doi.org/10.1371/journal.pone.0202330.t003TheAYAswhowerethefocusofthisstudyhadmanycomorbiditiesandvulnerabilitiespredatingtheonsetoftheirgenderdysphoria,includingpsychiatricdisorders,neurodevelopmentaldisabilities,trauma,non-suicidalself-injury(NSSI),anddifficultiescopingwithstrongornegativeemotions(Table4).Themajority(62.5%)ofAYAshadoneormorediagnosesofapsychiatricdisorderorneurodevelopmentaldisabilityprecedingtheonsetofgenderdysphoria(rangeofthenumberofpre-existingdiagnoses0–7).Many(48.4%)hadexperiencedatraumaticorstressfuleventpriortotheonsetoftheirgenderdysphoria.Opentextdescriptionsoftraumawerecategorizedas“family”(includingparentaldivorce,deathofaparent,mentaldisorderinasiblingorparent),“sexorgenderrelated”(suchasrape,attemptedrape,sexualharassment,abusivedatingrelationship,break-up),“social”(suchasbullying,socialisolation),“moving”(familyrelocationorchangeofschools);“psychiatric”(suchaspsychiatrichospitalization),andmedical(suchasseriousillnessormedicalhospitalization).Almosthalf(45.0%)ofAYAswereengaginginnon-suicidalself-injury(NSSI)behaviorbeforetheonsetofgenderdysphoria.CopingstylesfortheseAYAsincludedhavingapoororextremelypoorabilitytohandlenegativeemotionsproductively(58.0%)andbeingoverwhelmedbystrongemotionsandtryingtoavoid(orgotogreatlengthstoavoid)experiencingthem(61.4%)(Table4).Themajorityofrespondents(69.4%)answeredthattheirchildhadsocialanxietyduringadolescence;44.3%thattheirchildhaddifficultyinteractingwiththeirpeers,and43.1%thattheirchildhadahistoryofbeingisolated(notassociatingwiththeirpeersoutsideofschoolactivities). Download: PPTPowerPointslidePNGlargerimageTIFForiginalimageTable4.AYAbaselinecomorbiditiesandvulnerabilitiespredatingtheonsetofgenderdysphoria. https://doi.org/10.1371/journal.pone.0202330.t004 Announcingatransgender-identification AtthetimetheAYAannouncedtheyweretransgender-identified(“cameout”),mostwerelivingathomewithoneorbothparents(88.3%)andasmallnumberwerelivingatcollege(6.2%).Theaverageageofannouncementofatransgender-identificationwas15.2yearsofage(range10–21)(Table5).Mostoftheparents(80.9%)answeredaffirmativelythattheirchild’sannouncementofbeingtransgendercame“outofthebluewithoutsignificantpriorevidenceofgenderdysphoria.”Respondentswereaskedtopinpointatimewhentheirchildseemednotatallgenderdysphoricandtoestimatethelengthoftimebetweenthatpointandtheirchild’sannouncementofatransgender-identity.Almostathirdofrespondents(32.4%)notedthattheirchilddidnotseemgenderdysphoricwhentheymadetheirannouncementand26.0%saidthelengthoftimefromnotseeminggenderdysphorictoannouncingatransgenderidentitywasbetweenlessthanaweektothreemonths.Themoststrikingexamplesof“notseemingatallgenderdysphoric”priortomakingtheannouncementincludedadaughterwholovedsummersandseemedtolovehowshelookedinabikini,anotherdaughterwhohappilyworebikinisandmakeup,andanotherdaughterwhopreviouslysaid,“Ilovemybody!” Themajorityofrespondents(69.2%)believedthattheirchildwasusinglanguagethattheyfoundonlinewhenthey“cameout.”Atotalof130participantsprovidedoptionalopentextresponsestothisquestion,andresponsesfellintothefollowingcategories:whytheythoughtthechildwasusinglanguagetheyfoundonline(51);descriptionofwhatthechildsaidbutdidn’tprovideareasonthattheysuspectedthechildwasusinglanguagetheyfoundonline(61);somethingelseabouttheconversation(8)orthechild(7)anddon’tknow(3).Ofthe51responsesdescribingreasonswhyrespondentsthoughttheirchildwasreproducinglanguagetheyfoundonline,thetoptworeasonswerethatitdidn’tsoundliketheirchild’svoice(19respondents)andthattheparentlaterlookedonlineandrecognizedthesamewordsandphrasesthattheirchildusedwhentheyannouncedatransgenderidentity(14respondents).Theobservationthatitdidn’tsoundliketheirchild’svoicewasalsoexpressedas“soundingscripted,”liketheirchildwas“readingfromascript,”“wooden,”“likeaformletter,”andthatitdidn’tsoundliketheirchild’swords.Parentsdescribedfindingthewordstheirchildsaidtothem“verbatim,”“wordforword,”“practicallycopyandpaste,”and“identical”inonlineandothersources.Thefollowingquotescapturethesetoptwoobservations.Oneparentsaid,“Itseemeddifferentfromthewaysheusuallytalked—Irememberthinkingitwaslikehearingsomeonewhohadmemorizedalotofdefinitionsforavocabularytest.”Anotherrespondentsaid,“Theemail[mychildsenttome]readlikeallofthenarrativespostedonlinealmostwordforword.” Download: PPTPowerPointslidePNGlargerimageTIFForiginalimageTable5.Announcingatransgender-identification. https://doi.org/10.1371/journal.pone.0202330.t005Thefollowingcasesummarieswereselectedtoillustratepeer,trauma,andpsychiatriccontextsthatmightindicatemorecomplicatedclinicalpictures. A12-year-oldnatalfemalewasbulliedspecificallyforgoingthroughearlypubertyandtherespondingparentwrote“asaresultshesaidshefeltfatandhatedherbreasts.”Shelearnedonlinethathatingyourbreastsisasignofbeingtransgender.Sheeditedherdiary(bycrossingoutexistingtextandwritinginnewtext)tomakeitappearthatshehasalwaysfeltthatsheistransgender. A14-year-oldnatalfemaleandthreeofhernatalfemalefriendsweretakinggrouplessonstogetherwithaverypopularcoach.Thecoachcameoutastransgender,and,withinoneyear,allfourstudentsannouncedtheywerealsotransgender. Anatalfemalewastraumatizedbyarapewhenshewas16yearsofage.Beforetherape,shewasdescribedasahappygirl;aftertherape,shebecamewithdrawnandfearful.Severalmonthsaftertherape,sheannouncedthatshewastransgenderandtoldherparentsthatsheneededtotransition. A21-year-oldnatalmalewhohadbeenacademicallysuccessfulataprestigiousuniversityseemeddepressedforaboutsixmonths.Sinceconcludingthathewastransgender,hewentontohaveamarkeddeclineinhissocialfunctioningandhasbecomeincreasinglyangryandhostiletohisfamily.Herefusestomoveoutorlookforajob.Hisentirefamily,includingseveralmemberswhoareverysupportiveofthetransgendercommunity,believethatheis“sufferingfromamentaldisorderwhichhasnothingtodowithgender.” A14-year-oldnatalfemaleandthreeofhernatalfemalefriendsarepartofalargerfriendgroupthatspendsmuchoftheirtimetalkingaboutgenderandsexuality.Thethreenatalfemalefriendsallannouncedtheyweretransboysandchosesimilarmasculinenames.Afterspendingtimewiththesethreefriends,the14-year-oldnatalfemaleannouncedthatshewasalsoatransboy. Themajority(76.5%)ofthesurveyedparentsfeltthattheirchildwasincorrectintheirbeliefofbeingtransgender(Table5).Morethanathird(33.7%)oftheAYAsaskedformedicaland/orsurgicaltransitionatthesametimethattheyannouncedtheyweretransgender-identified.Twothirds(67.2%)oftheAYAstoldtheirparentthattheywantedtotakecross-sexhormones;58.7%thattheywantedtoseeagendertherapist/genderclinic;and53.4%thattheywantedsurgeryfortransition.Almostathird(31.2%)ofAYAsbroughtuptheissueofsuicidesintransgenderteensasareasonthattheirparentshouldagreetotreatment.MorethanhalfoftheAYAs(55.9%)hadveryhighexpectationsthattransitioningwouldsolvetheirproblemsinsocial,academic,occupationalormentalhealthareas.While43.9%ofAYAswerewillingtoworkonbasicmentalhealthbeforeseekinggendertreatments,asizableminority(28.1%)werenotwillingtoworkontheirbasicmentalhealthbeforeseekinggendertreatment.Atleasttwoparentsrelayedthattheirchilddiscontinuedpsychiatriccareandmedicationsforpre-existingmentalhealthconditionsoncetheyidentifiedastransgender.Oneparent,inresponsetothequestionaboutiftheirchildhadveryhighexpectationsthattransitioningwouldsolvetheirproblemselaborated,“Verymuchso.[She]discontinuedanti-depressantquickly,stoppedseeingpsychiatrist,beganseeinggendertherapist,stoppedhealthyeating.[She]stated‘noneofit’(mindingwhatsheateandtakingherRx)‘matteredanymore.’Thiswashercure,inheropinion.” Friend-groupexposure Theadolescentandyoungadultchildrenwere,onaverage,14.4yearsoldwhentheirfirstfriendbecametransgender-identified(Table6).Withinfriendshipgroups,theaveragenumberofindividualswhobecametransgender-identifiedwas3.5pergroup.In36.8%ofthefriendgroupsdescribed,themajorityofindividualsinthegroupbecametransgender-identified.TheorderthatthefocalAYA“cameout”comparedtotherestoftheirfriendshipgroupwascalculatedfromthe119participantswhoprovidedthenumberoffriendscomingoutbothbeforeandaftertheirchildand74.8%oftheAYAswerefirst,secondorthirdoftheirgroup.Parentsdescribedintensegroupdynamicswherefriendgroupspraisedandsupportedpeoplewhoweretransgender-identifiedandridiculedandmalignednon-transgenderpeople.Wherepopularitystatusandactivitieswereknown,60.7%oftheAYAsexperiencedanincreasedpopularitywithintheirfriendgroupwhentheyannouncedatransgender-identificationand60.0%ofthefriendgroupswereknowntomockpeoplewhowerenottransgenderorLGBTIA(lesbian,gay,bisexual,transgender,intersex,orasexual). Download: PPTPowerPointslidePNGlargerimageTIFForiginalimageTable6.Friendgroupexposure. https://doi.org/10.1371/journal.pone.0202330.t006Forthequestionaboutpopularitychangeswhenthechildcameoutashavingatransgender-identification,79participantsprovidedoptionalopentextresponseswhichwerecategorizedas:descriptionsoftheresponsesthechildreceived(39);descriptionsofthefriends(14);descriptionthatthechilddidnot“comeout”tofriends(8);notsure(9);speculationonhowthechildfeltfromtheresponse(4),other(5).Ofthe39descriptionsofresponses,19oftheseresponsesreferredtopositivebenefitsthechildreceivedaftercomingoutincludingpositiveattention,compliments,increasedstatus,increasedpopularity,increasednumbersofonlinefollowers,andimprovedprotectionfromongoingbullying.Thefollowingarequotesfromparentsabouttheperceivedbenefitsoftransgender-identificationaffordedtotheirchild.Onerespondentsaid,“Greatincreaseinpopularityamongthestudentbodyatlarge.Beingtransisagoldstarintheeyesofotherteens.”Anotherrespondentexplained,“notsomuch‘popularity’increasingas‘status’…alsoshebecameuntouchableintermsofbullyinginschoolasteacherswhoignoredhomophobicbullying…arenowallatpainstobehotontheheelsofanytransbullying.”Sevenrespondentsdescribedamixedresponsewherethechild’spopularityincreasedwithsomefriendsanddecreasedwithothers.Sevenrespondentsdescribedaneutralresponsesuchas“Allofthefriendsseemedextremelyaccepting.”Twodescribedatemporaryincreaseintheirchild’spopularity:“Therewasanimmediaterushofsupportwhenhecameout.Thosesamefriendshavedwindledtonothingasherarelyspeakstoanyofthemnow.”Anotherdescribedthelossoffriends.Andtwoparentsdescribedthat“comingout”preventedthelossoffriendsexplainedbyonerespondentas“tonotbetransonewouldnothavebeenincludedinhisgroup.” SeveralAYAsexpressedsignificantconcernaboutthepotentialrepercussionsfromtheirfriendgroupwhentheyconcludedthattheywerenottransgenderafterall.ThereweretwounrelatedcaseswithsimilartrajectorieswheretheAYAsspentsomesignificanttimeinadifferentsetting,awayfromtheirusualfriendgroup,withoutaccesstotheinternet.ParentsdescribedthattheseAYAsmadenewfriendships,becameromanticallyinvolvedwithanotherperson,andduringtheirtimeawayconcludedthattheywerenottransgender.Inbothcases,theadolescents,ratherthanfacetheirschoolfriends,askedtomoveandtransfertodifferenthighschools.Oneparentsaidthattheirchild,“…couldn’tfacethestigmaofgoingbacktoschoolandbeingbrandedasafakeorphony.…Orworse,atraitororsomekindofbetrayer…[and]askedusifwecouldmove.”Intheothercase,theparentrelayedthattheirchildthoughtnoneoftheoriginalfriendswouldunderstandandexpressedastrongdesireto“…getoutoftheculturethat‘ifyouarecis,thenyouarebadoroppressiveorclueless.’”Bothfamilieswereabletorelocateandbothrespondentsreportedthattheirteenshavethrivedintheirnewenvironmentsandnewschools.Onerespondentdescribedthattheirchildexpressedreliefthatmedicaltransitionwasneverstartedandfelttherewouldhavebeenpressuretomoveforwardhadthefamilynotmovedawayfromthepeergroup. Qualitativeanalysis Theopen-endedresponsesfromthequestionaboutwhethertheAYAsandfriendsmocked,teased,ormadefunofindividualswhoweren’ttransgenderorLGBTIAwasselectedforadditionalqualitativeanalysis.Sevenmajorthemeswereidentifiedfromthecommentsprovidedbyparticipantsandaredescribed,withrepresentativesupportingquotes. Theme:Groupstargeted.Thegroupstargetedformockingbythefriendgroupsareoftenheterosexual(straight)peopleandnon-transgenderpeople(called“cis”or“cisgender”).Sometimesanimositywasalsodirectedtowardsmales,whitepeople,gayandlesbian(non-transgender)people,aromanticandasexualpeople,and“terfs”.Oneparticipantexplained,“Theyareconstantlyputtingdownstraight,whitepeopleforbeingprivileged,dumbandboring.”Anotherparticipantelaborated,“Ingeneral,cis-genderedpeopleareconsideredevilandunsupportive,regardlessoftheiractualviewsonthetopic.Tobeheterosexual,comfortablewiththegenderyouwereassignedatbirth,andnon-minorityplacesyouinthe‘mostevil’ofcategorieswiththisgroupoffriends.Statementofopinionsbytheevilcis-genderedpopulationareconsiderphobicanddiscriminatoryandaregenerallydiscountedasunenlightened.” Theme:Individualstargeted.Inadditiontotargetingspecificgroupsofpeopleformocking,theAYAsandtheirfriendgroupsalsodirectedmockingtowardsindividualsintheAYAs’livessuchasparents,grandparents,siblings,peers,allies,andteachers.Thefollowingquotesdescribeindividualstargeted.Oneparticipantsaid,“TheycallkidswhoarenotLGBTdumbandcis.Andthemockinghasbeenaimedatmytransgender-identifiedchild’s[sibling].”Anotherparentsaid,“Theydefinitelymadefunofparentsandteacherswhodidnotagreewiththem.”Andathirdparticipantsaid,“…theywereaskedtoleave[aschool-basedLGBTclub]becausetheywerenotqueerenough[asstraightandbisexualallies].[Oneofthem]was[then]bullied,harassedanddenouncedonline.” Theme:Behaviorsoccurredbothinpersonandinonlinesettings.Parentsobservedthebehaviorsbothin-personandinonlinesettings,andspecificallymentionedseeingpostsandconversationsonTumblr,Twitter,Facebook,andInstagram.Onparticipantsaid,“Theyspeakwithderisionabouthowcis-genderedpeopledonotunderstandthemandaresoclose-minded.”Anotherparticipantsaid,“Ihearthemdisparagingheterosexuality,marriageandnuclearfamilies.”Anotherparticipantsaid,“Onmydaughter'sTumblrblog,shehaslikedorfavoritedorre-posteddisparagingcommentsaboutthosewhoaren'ttransgenderorseemtomisunderstandthetransgenderidentity.”Andanotherparentreported,“Herreallifefriendsdon't[mocknon-LGBTpeople]butonlinetheyarealwaysswappingjokesandcommentsaboutcisgenderandabouttransphobia.” Theme:Examplesofbehaviors.Participantsgavemanyexamplesoftheobservedbehaviorsthatweremockingtowardsnon-transgenderpeopleandnon-LGBpeople.Oneparticipantsaid,“Mydaughtercalledmea‘breeder’andsaysthingsinamocking‘straightpersonvoice’.Herfriendseggheronwhenshedoesthis.”Anotherparentoffered,“Iftheyaren'tmocking‘cis’people,theyareplayingpronounpoliceandmockingpeoplewhocan'tgetthepronounscorrect.”Anotherparticipantsaid,“Newvocabularyincludes‘cis-stupid’and‘cis-stupidity.’”Andafourthparticipantdescribed,“Theyassumeanyonethatiscriticalaboutbeingtransgender(evenjustaskingquestions)iseitherignorantorfilledwithhate.” Theme:Emphasizingvictimhood.Participantsdescribedthattheirchildrenandfriendgroupseemedtofocusonfeelingasthoughtheywerevictims.Oneparticipantdescribed,“Theyseemtowearanyproblemstheymayhave,realorperceivedlikebadgesofhonor…Ifeelliketheywanttobelievetheyareoppressed&havereally'beenthroughlife',whentheyhavelittlelifeexperience.”Anotherparticipantsaid,“…thereisalotoffeelinglikeavictim[andbeing]partofavictimizedclub.”Anotherparentsaid“Butalltalkisvery'victim'centered”.Andfinally,anothersaid,“Theypassionatelydecry‘StraightPrivilege’and‘WhiteMalePrivilege’—whileemphasizingtheirown‘Victimhood.’” Theme:Consequencesofbehaviors.Afewparticipantsdescribethatbecauseoftheirchild’sbehavior,therewereconsequences,includingmakingitdifficultforonechildtoreturntoherschoolandthefollowingdescriptionfromanotherparent,“Mostrelativeshaveblockedheron[socialmedia]overconstantjokesregardingcisandstraightpeople.” Theme:Fuelingthebehaviors.Insomecases,parentsdescribeasynergisticeffectofkidsencouragingotherkidstopersistinthebehavioraswasdescribedinapreviousquote,“Herfriendseggheronwhenshedoesthis”aswellasthefollowing,“Lotsofdiscussionrevolvingaroundhowtheirteachers‘discriminate’orare‘mean’tothembasedontheirdeclaredLGBTIAidentity,andtheygeteachotherriledupconvincingeachotheroftheirpersecutionbytheseperceivedwrongs…privatelytheymockourintolerance,andinpersonactuponthesefalsebeliefsbytreatingusaspeopleouttogetthem…” Internet/socialmediaexposure Inthetimeperiodjustbeforeannouncingthattheyweretransgender,63.5%ofAYAsexhibitedanincreaseintheirinternet/socialmedia(Table7).ToassessAYAexposuretoexistingonlinecontent,parentswereaskedwhatkindofadvicetheirchildreceivedfromsomeone/peopleonline.AYAshadreceivedonlineadviceincludinghowtotelliftheyweretransgender(54.2%);thereasonsthattheyshouldtransitionrightaway(34.7%);thatiftheirparentsdidnotagreeforthemtotakehormonesthattheparentswere“abusive”and“transphobic”(34.3%);thatiftheywaitedtotransitiontheywouldregretit(29.1%);whattosayandwhatnottosaytoadoctorortherapistinordertoconvincethemtoprovidehormones(22.3%);thatiftheirparentswerereluctanttotakethemforhormonesthattheyshouldusethe“suicidenarrative”(tellingtheparentsthatthereisahighrateofsuicideintransgenderteens)toconvincethem(20.7%);andthatitisacceptabletolieorwithholdinformationaboutone’smedicalorpsychologicalhistoryfromadoctorortherapistinordertogethormones/gethormonesfaster(17.5%).Tworespondents,inanswerstootherquestions,describedthattheirchildrenlatertoldthemwhattheylearnedfromonlinediscussionlistsandsites.Oneparentreported,“Hehastoldusrecentlythathewasonabunchofdiscussionlistsandlearnedtipsthere.Placeswhereteensandothertranspeopleswapinfo.Liketouse[certain,specific]words[with]thetherapistwhendescribingyourGD,because[theyare]codeforpotentiallysuicidalandwillgetyouadiagnosisandRxforhormones.”Anotherparentdisclosed,“Thethreatofsuicidewashugeleverage.Whatdoyousaytothat?It’shardtohaveasteadyhandandsaynotomedicaltransitionwhentheotheroptionisdeadkid.Shelearnedthingstosaythatwouldpushourbuttonsandgetwhatshewantedandshehastoldusnowthatshelearnedthatfromtransdiscussionsites.” Download: PPTPowerPointslidePNGlargerimageTIFForiginalimageTable7.Internet/Socialmediaexposures. https://doi.org/10.1371/journal.pone.0202330.t007Parentsidentifiedthesourcestheythoughtweremostinfluentialfortheirchildbecominggenderdysphoric.Themostfrequentlyansweredinfluenceswere:YouTubetransitionvideos(63.6%);Tumblr(61.7%);agroupoffriendstheyknowinperson(44.5%);acommunity/groupofpeoplethattheymetonline(42.9%);apersontheyknowin-person(notonline)41.7%.Incontrasttothemajorityofresponses,twoparticipantscommentedthattheydidn’tthinkthesourcesinfluencedtheirchildtobecomegenderdysphoric,rathertheygavetheirchildanamefortheirfeelingsorgavethechildconfidencetocomeout.Thefollowingquotesillustratethedominantquantitativefindings.Oneparentwrote,“Webelievethebiggestinfluencewastheonlinepro-transitionblogsandyoutubevideos.Wefeelshewashighlyinfluencedbythe‘ifyouareevenquestioningyourgender-youareprobablytransgender’philosophy…Inthe‘realworld’herfriends,othertranspeers,andnewfoundpopularitywereadditionalareasofreinforcement.”Anotherrespondentdescribedtheonlineinfluenceaspartofadifferentquestion,“Ibelievemychildexperiencedwhatmanykidsexperienceonthecuspofpuberty—uncomfortableness!—buttherewasanonlineworldatthereadytotellherthatthoseverynormalfeelingsmeantshe'sinthewrongbody.” Mentalwell-being,mentalhealth,andbehaviors ThetrajectoriesoftheAYAswerenotconsistentwiththenarrativeofdiscoveringone’sauthenticselfandthenthriving.Specifically,parentsreportedthat,after“comingout,”theirchildrenexhibitedaworseningoftheirmentalwell-being.Additionally,parentsnotedworseningoftheparent-childrelationshipandobservedthattheirchildrenhadnarrowedtheirinterests(Table8).AlthoughsmallnumbersofAYAshadimprovementinmentalwell-being(12.6%),parent-childrelationship(7.4%),grades/academicperformance(6.4%),andhadbroadenedtheirinterestsandhobbies(5.1%);themostcommonoutcomeswereworsenedmentalwell-being(47.2%);worsenedparentchildrelationship(57.3%);unchangedormixedgrades/academicperformance(59.1%);andanarrowedrangeofinterestsandhobbies(58.1%).Oneparentdescribingherchild’strajectoryoffered,“Afterannouncingshewastransgender,mydaughter’sdepressionincreasedsignificantly.Shebecamemorewithdrawn.Shestoppedparticipatinginactivitieswhichshepreviouslyenjoyed,stoppedparticipatinginfamilyactivities,andsignificantlydecreasedherinteractionwithfriends.Hersymptomsbecamesoseverethatshewasplacedonmedicationbyherphysician.”Table9describescumulativeratesofmentalillnessandneurodevelopmentaldisabilityatthetimeofsurvey. Download: PPTPowerPointslidePNGlargerimageTIFForiginalimageTable8.Outcomesandbehaviors. https://doi.org/10.1371/journal.pone.0202330.t008 Download: PPTPowerPointslidePNGlargerimageTIFForiginalimageTable9.AYACumulativementaldisorderandneurodevelopmentaldisabilitydiagnoses. https://doi.org/10.1371/journal.pone.0202330.t009Atotalof63.8%oftheparentshavebeencalled“transphobic”or“bigoted”bytheirchildrenforoneormorereasons,themostcommonbeingfor:disagreeingwiththechildaboutthechild’sself-assessmentofbeingtransgender(51.2%);recommendingthatthechildtakemoretimetofigureoutiftheirfeelingsofgenderdysphoriapersistorgoaway(44.6%);expressingconcernsforthechild’sfutureiftheytakehormonesand/orhavesurgery(40.4%);callingtheirchildbythepronounstheyusedtouse(37.9%);tellingthechildtheythoughtthathormonesorsurgerywouldnothelpthem(37.5%);recommendingthattheirchildworkonothermentalhealthissuesfirsttodetermineiftheyarethecauseofthedysphoria(33.3%);callingthechildbytheirbirthname(33.3%);orrecommendingacomprehensivementalhealthevaluationbeforestartinghormonesand/orsurgery(20.8%)(Table10).Therewereeightcasesofestrangement.Estrangementwaschild-initiatedinsixcaseswherethechildranaway,movedout,orotherwiserefusedcontactwithparent.ThereweretwocaseswheretheestrangementwasinitiatedbytheparentbecausetheAYA’soutburstswereaffectingyoungersiblingsortherewasathreatofviolencemadebytheAYAtotheparent. Download: PPTPowerPointslidePNGlargerimageTIFForiginalimageTable10.Additionalbehaviors. https://doi.org/10.1371/journal.pone.0202330.t010AYAsarereportedtohaveexhibitedoneormoreofthefollowingbehaviors:expresseddistrustofinformationaboutgenderdysphoriaandtransgenderismcomingfrommainstreamdoctorsandpsychologists(51.8%);triedtoisolatethemselvesfromtheirfamily(49.4%);expressedthattheyonlytrustinformationaboutgenderdysphoriaandtransgenderismthatcomesfromtransgenderwebsitesand/ortransgenderpeopleandsources(46.6%);lostinterestinactivitieswhereparticipantsaren’tpredominantlytransgenderorLGBTIA(32.3%);stoppedspendingtimewithfriendswhowerenottransgender(25.1%);expresseddistrustofpeoplewhowerenottransgender(22.7%)(Table10).ManyAYAshavealso:withdrawnfromtheirfamily(45.0%);toldotherpeopleorpostedonsocialmediathattheirparentis“transphobic,”“abusive,”or“toxic”becausetheparentdoesnotagreewithchild’sself-assessmentofbeingtransgender(43.0%);refusedtospeaktotheirparent(28.5%),defendedthepracticeoflyingtoorwithholdinginformationfromtherapistsordoctorsinordertoobtainhormonesfortransitionmorequickly(16.5%);triedtorunaway(6.8%).Thebehaviorsandoutcomeslistedabovewereconsideredsignificantchangesfromthechild’sbaselinebehaviorsfor71.4%ofrespondentscheckinganyoftheitems. Therewasasubsetofeightcaseswhereparentsdescribedwatchingtheirchildhavedecliningmentalwell-beingastheybecamegenderdysphoricandtransgender-identifiedandthenhadimprovingmentalwell-beingastheydroppedorbackedawayfromatransgender-identification.Oneparentdescribedamarkedchangeinherdaughterwhenshewasoutofschooltemporarily.“[Her]routinewasdisrupted.Shespentalldayontheinternet,andlosthermanyschoolfriends—heronlyfriendswereon-lineandmembersofthetranscommunity.Inthreemonths,mydaughterannouncedsheistrans,genderdysphoric,wantsbindersandtopsurgery,testosteroneshots…shestartedself-harming.Nowbackatschool…shetweetedthatshe’ssoyoung,isn’tsureifsheistrans,nolongerwantstobereferredtobythemalenameshehadchosen…SinceshehasstartedbackatschoolandisbeingexposedtoawidevarietyofpeoplesheisWAYhappier.”Anotherparentdescribed,“Mydaughter’sinsighthasimprovedconsiderablyoverthelastfewyears,andshehasalsooutgrownthebeliefthatsheistransgender.Mydaughteractuallyseemedtobelookingforareasonforherdepressionwhichisnowbeingsuccessfullytreated…MydaughterisMUCHhappiernowthatsheisbeingtreatedforhergenuineissues.Comingoutastransmadehermuchworseforawhile.” Therewasasubsetof30caseswheretheAYAs’transgender-identificationoccurredinthecontextofadeclineintheirabilitytofunction(suchasdroppingoutofhighschoolorcollege,needingaleaveofabsencefromhighschoolorcollege,and/orbeingunabletoobtainorholdajob),whichparentsreportedasasignificantchangefromtheirchild’sbaselinebehavior.Thedeclinesweresubstantialas43.3%oftheseAYAshadbeenidentifiedasacademicallygiftedstudents(somedescribedastopoftheirclassinhighschool,earningoutstandinggradesatprestigiousuniversities)beforetheybegantofailtheirclasses,dropoutofhighschoolorcollege,andbecameunabletoholdajob.Inmostofthesecases(76.7%),therewasoneormorepsychiatricdiagnosismadeatthesametimeorwithintheyear(60.0%)orwithintwoyears(16.7%)oftheAYA’snewtransgender-identification.Ofthe23individualswhohadapsychiatricdiagnosismadewithintwoyearsofassumingatransgender-identification,91.3%(21/23)werediagnosedwithdepression;73.9%(17/23)withanxiety;26.0%(6/23)withbipolardisorder;17.4%(4/23)withborderlinepersonalitydisorder;8.7%(2/23)withpsychosis/psychoticepisode:and8.7%(2/23)withaneatingdisorder. Clinicalencounters Parentswereaskediftheirchildhadseenagendertherapist,gonetoagenderclinic,orseenaphysicianforthepurposeofbeginningtransitionand92respondents(36.2%)answeredintheaffirmative(Table11).Manyoftherespondentsclarifiedthattheirchildhadseenaclinicianregardingtheirgenderdysphoriaforevaluationonly.Althoughparticipantswerenotaskeddirectlywhatkindofprovidertheirchildsaw,specialtiesthatwerementionedinanswersincluded:generalpsychologists,pediatricians,familydoctors,socialworkers,gendertherapists,andendocrinologists.Forparentswhoknewthecontentoftheirchild’sevaluation,71.6%reportedthatthecliniciandidnotexploreissuesofmentalhealth,previoustrauma,oranyalternativecausesofgenderdysphoriabeforeproceedingand70.0%reportthatthecliniciandidnotrequestanymedicalrecordsbeforeproceeding.DespitealloftheAYAsinthisstudysamplehavinganatypicalpresentationofgenderdysphoria(nogenderdysphoriapriortopuberty),23.8%oftheparentswhoknewthecontentoftheirchild’svisitreportedthatthechildwasofferedprescriptionsforpubertyblockersand/orcross-sexhormonesatthefirstvisit. Download: PPTPowerPointslidePNGlargerimageTIFForiginalimageTable11.Interactionswithclinicians. https://doi.org/10.1371/journal.pone.0202330.t011Oneparticipantdescribed,“Forthemostpart,IwasextremelyfrustratedwithprovidersNOTacknowledgingthementaldisorder,anxiety,depression,etcbeforerecommendinghormonereplacementtherapy.”Andtwoparticipantsdescribedhowthecliniciantreatingtheirchild’sgenderdysphoriarefusedtospeakwiththepatients’primarycarephysicians.Oneparticipantsaid,“Whenwephonedtheclinic,thedoctorwashostiletous,toldustomindourownbusiness.Ourfamilydoctortriedtoreachourson’snewdoctor,butthetransdoctorrefusedtospeakwithher.”Anotherrespondentshared“Thepediatrician/‘genderspecialist’didnotreturncallsoremailsfromtheprimarycarephysicianwhorequestedtotalkwithheraboutmyson’smedicalhistorybeforeshesawandtreatedhim…shedisregardedallhistoricalinformationprovidedbythefamilyandprimarycarephysician…didnotverifyanyinformationprovidedbymy…sonathisfirstvisitevenafterbeingprovidedwithmultipleotherhistoricalsourceswhichdifferedsignificantlyfromhisstory.” Whenaskedaboutwhethertheirchildrelayedtheirhistorycompletelyandaccuratelytocliniciansorwhethertheymisrepresentedoromittedpartsoftheirhistory,ofthosewhoknewthecontentoftheirchild’svisit,84.2%oftheparentrespondentswerereasonablysureorpositivethattheirchildhadmisrepresentedoromittedpartsoftheirhistory.Twenty-eightparticipantsprovidedoptionalopentextresponsestothisquestionandtheresponseswerecategorizedinto:describinghowtheparentknewthatthechildmisrepresentedtheirhistory(5);thecontentofwhatthechildmisrepresented(6misrepresentingingeneral,4misrepresentingtotheclinicianforatotalof10examples);don’tknow/notsure(4);expressingcertainty(1);andnotrelevant(8).Forthefiveparticipantsdescribinghowtheyknew,thereasonsincluded:beingpresentwhenithappened,readingthereportfromthegenderspecialist,beingtoldbytheirchildthatthechildhadmisrepresentedthetruth,andbeinginformedbythechild’spsychiatrist.Onerespondentshared,“Ihavereadthereportfromthegenderspecialistanditomitsalltherelevantcontextpaintinganalmostunrecognizablepictureofmyson.”Asecondparentsimplyresponded,“Iwaspresent.”Anotherrespondentrelayedabouttheir(natalmale)child,“Mydaughtertoldmeandhermotherthatthefirsttherapistshesawaskedherstereotypicalquestions…Shewasafraidthatifshedidn’tdescribeherselfasa‘typicalgirl’shewouldnotbebelieved.”Andfinally,onerespondentwrote,“Hehassaidnowthathedid[misrepresenthishistory]andusedkeywordshewasadvisedtosay.”Tenparticipantsprovided13examplesofthecontentofmisrepresentationsandofthese,6examplescouldhavebeeneasilyverifiedtobefalse(claimingtobeunderthecareofapsychiatrist,claimingtobeonmedicationtotreatapsychiatriccondition,howonewasdoingacademically,andclaimingachildhoodhistoryofhavingplaymatesofonesexwhentheoppositewasobserved,andclaimingstrongchildhoodpreferencesforspecifictoysandclothingthatistheoppositeofwhatmultipleindividualsobserved).Threeofthecontentexampleswouldhavebeenchallengingtoverifyasfalseincluding:howonewasfeelingasachild,howonewasfeelingwhenapicturewastaken,andwhetheronewasfromanabusivehome.Andfourofthecontentexamplesdidnotprovideenoughinformationtodetermineiftheywouldbeeasyorchallengingtoverifyasfalse,suchas“Mychilddistortsherhistoryandourfamilylifeonaregularbasis,”and“Hehascreatedanentirenarrativethatjustisn’ttrue.” Inadditiontothepreviouslymentionedcasewherethechildliterallyrewroteherhistorybyeditingherdiary,thereweresevenrespondentswhoconveyedaprocesswheretheirchildwasconstantlyrewritingtheirpersonalhistorytomakeitconsistentwiththeideathattheyalwaysweretransgenderand/orhadcreatedachildhoodhistorythatwasnotwhatothershadobserved.Itisunclearwhetherthisprocesswasdeliberateoriftheindividualswereunawareoftheiractions.Thefollowingarequotesdescribingthisphenomenon.Oneparentsaid,“…sheisactivelyrewritingherpersonalhistorytosupporttheideathatshewasalwaystrans.”Anotherrespondentadded,”…mydaughterdenieseventsIrecollectfromherchildhoodandpubertythatcontradictshernarrativeof‘alwaysknowingshewasaboy.’”Anotherrespondentoffered,“Heisrewritinghispersonalhistorytosuithisnewnarrative.”Andafourthrespondentdescribed,“[Our]sonhascompletelymadeuphischildhoodtoincludeonlygirlfriendsanddressingupingirlsclothesandplayingwithdolls,etc.Thisisnotthesamechildhoodwehaveseenasparents.” Qualitativeanalysis Theopen-endedcommentsfromthequestionaboutwhethertheclinicianexploredmentalhealth,traumaoralternativecausesofgenderdysphoriabeforeproceedingwereselectedforqualitativeanalysis.Ninemajorthemesemergedfromthedata.Eachthemeisdescribedinthefollowingparagraphswithsupportingquotesfromparticipants. Theme:Failuretoexplorementalhealth,traumaoralternativecausesofGD.Parentsdescribedthatcliniciansfailedtoexploretheirchild’smentalhealth,trauma,oranyalternativecausesforthechild’sgenderdysphoria.Thisfailuretoexplorementalhealthandtraumaoccurredevenwhenpatientshadahistoryofmentalhealthdisorderortrauma,werecurrentlybeingtreatedforamentalhealthdisorder,orwerecurrentlyexperiencingsymptoms.Oneparticipantsaid,“Nothingotherthangenderdysphoriawasconsideredtoexplainmydaughter'sdesiretotransition.”Anotherparticipantsaid,“Mydaughtersawachildtherapistandthetherapistwaspreparingtosupporttransgenderinganddidnotexplorethedepressionandanxietyorprevioustrauma.” Theme:Insufficientevaluation.Anotherthemewasinsufficientevaluationwhereparentsdescribedevaluationsthatweretoolimitedortoosuperficialtoexplorementalhealth,traumaoralternativecausesofgenderdysphoria.Thefollowingarethreequotesbythreedifferentparentsdescribinginsufficientevaluations.Oneparentsaid,“Theexplorationwasegregiouslyinsufficient,veryshallow,noefforttoaskquestions,engageincriticalthinkingaboutcoexistinganxiety,orputonthebrakesorevenslowdown.”Anotherparticipantstated,“Whenwetriedtogiveourson’stransdoctoramedicalhistoryofourson,sherefusedtoacceptit.Shesaidthehalfhourdiagnosisinherofficewithhimwassufficient,assheconsidersherselfanexpertinthefield.”Andathirdparentwrote,“WewereSTUNNEDbythelackofinformation,medicalhistorysoughtbytherapistandradicaltreatmentsuggestion.[One]visit.Theideais,‘iftheysaytheywereborninthewrongbody,theyare.Toquestionthiswillonlyhurtherandprolonghersuffering.’[Our]daughterhashadtraumain[the]past.[She]neverwasaskedaboutit.[The]therapistdidnotaskparentsasinglequestionaboutourdaughter.” Theme:Unwillingnessordisinterestinexploringmentalhealth,traumaoralternativecausesofGD.Parentsdescribedthatcliniciansdidnotseeminterestedorwillingtoexplorealternativecauses.Oneparentdescribed.“Hercurrenttherapistseemstoacceptherselfdiagnosisofgenderdysphoriaandfollowswhatshesayswithoutseemingtoomuchinterestedinexploringthesexualtraumainherpast.”Anotherparentwrote,“TheAspergerpsychiatristdidnotseemtocarewhetherourdaughter'sgenderdysphoriastemmedfromAsperger's.Ifourdaughterwantedtobemale,thenthatwasenough.”Andathirdparentsaid.“Thetherapistdidaskaboutthoseissuesbutseemedtowanttoaccepttheideawholeheartedlythatmydaughterwastransgenderfirstandforemost,allotherfactorsaside.” Theme:Mentalhealthwasexplored.Afewparentshadtheexperiencewheretheclinicianeithermadeanappropriatereferralforfurtherevaluationortheissueshadbeenaddressedpreviously.Oneparentsaid,“[The]previousmentalhealthissues[were]alreadyexploredbyothertherapists([my]childwasintherapyandmedicatedbeforecomingoutastransgender).” Theme:Failuretocommunicatewithpatients’medicalproviders.Severalparticipantsdescribedclinicianswhowereunwillingtocommunicatewithprimarycarephysiciansandmentalhealthprofessionalseventhoseprofessionalswhowerecurrentlytreatingthepatient.Oneparticipantrelayed,“ShedidnotreviewtheextensivepsychiatricrecordsthatwereavailableinasharedEMR[electronicmedicalrecord]andshedidnotconsultwithhisoutpatientpsychiatristpriortoorafterstartingcross-sexhormonaltherapy.”Anotherparentsaid,“Mychildhadbeenseenformentalhealthissuesforseveralyearsbeforepresentingthisnewidentity,buttheendocrinologistdidnotconsultthementalhealthprofessionalsfortheiropinionsbeforeofferinghormones.” Theme:Misrepresentationofinformationbythepatient.Severalparticipantsdescribedhowtheirchildmisrepresentedtheirhistorytotheclinician,thus,limitingtheclinician’sabilitytoadequatelyexplorementalhealth,traumaandalternativecauses.Oneparticipantwrote,“At[the]firstvisit,[my]daughter'sdialoguewaswell-rehearsed,fabricatedstoriesaboutherlifetoldtoget[the]outcomeshedesired.Sheparrotedpeoplefromtheinternet.”Anotherparentreported,“Mysonconcealedthetraumaandmentalhealthissuesthatheandthefamilyhadexperienced.”Andathirdparentsaid,“Ioverheardmysonboastingonthephonetohisolderbrotherthat‘thedocswallowedeverythingIsaidhook,lineandsinker.EasiestthingIeverdid.’” Theme:Transitionstepswerepushedbytheclinician.Someparentsdescribedclinicianswhoseemedtopushtheprocessoftransitionbeforethepatientaskedforit.Oneparentdescribedthatthedoctorgaveherdaughteraprescriptionthatshedidn’taskfor,“ThefamilydoctorwhogavehertheAndrogelRx[prescription]didNOTaskhermanyquestions(shewassurprisedbythis),nordidheawaitherassessmentbyalicensedpsychiatristbeforegivingherthisRx.NordidsheaskhimforthisRx.”Anotherparentreportedthatsheandherchildwereattheendocrinologist’sofficeonlytoaskquestions,anddescribed,“…[he]didn'tlistentoawordweweresaying.Hewastooeagertogetussetupwitha‘gendertherapist’togetthelegalformheneededtostarthormones,allwhilemakingsurewesetupournextappointmentwithin6monthstostartthehormones…” Theme:Parentviewswerediscountedorignored.Parentsdescribethatthecliniciansdidnottaketheirconcernsseriously.Oneparentdescribed,“IhavetosayIdon'tknow,butitishardtobelievethattheyadequatelyexaminedthehistoryofbullyingandbeingostracizedforbeingdifferent,andtheautistictraitsthatwouldlendapersonlikemysontoriskeverythingforidentifyingwithagroup.IknowthatinthefewcontactsIhadwiththeproviders,myconcernswerediscounted.”Andanothersaid,“Allofouremailswentunansweredandwereignored.Weareleftoutofeverythingbecauseofourconstantquestioningofthisbeingrightforourdaughter[becauseofher]traumaandcurrentdepression,anxietyandself-esteemproblems.” Theme:Parenthadconcernsabouttheclinicians’competence,professionalismorexperience.Parentsexpresseddoubtsaboutthecliniciansregardingtheirexperience,competenceorprofessionalism.Oneparentsaid,“Theclinictoldmetheyexploredtheseissues.Iaskedtheriskmanagerat[redacted]ifthey'dconsideredapersonalitydisorder.‘Oh,no,’shelaughed.‘That'sonlywiththeolderpatients,nottheteenagers.’I'mdeeplysuspiciousoftheircompetence.”Anotherparentdescribed,“Whatdoesconcernmeisthatthepeopleshetalkedtoseemedtohavenosenseofprofessionalduties,butonlyamissiontopromoteaspecificsocialideology.” Stepstowardstransitionandcurrentidentificationstatus ThissectionreportsonthedurationofAYAtransgender-identification(timefromtheAYA’sannouncementofatransgenderidentityuntilthetimetheparentcompletedthesurvey)thatcovers,onaverage,15.0months(range0.1–120months)withamedianof11months(Table12).ThestepstakentowardstransitionduringthistimeframearelistedinTable12.Attheendofthetimeframe,83.2%oftheAYAswerestilltransgender-identified,5.5%werenotstilltransgender-identified(desisted),2.7%seemedtobebackingawayfromtransgender-identification,and8.6%oftheparentsdidnotknowiftheirchildwasstillidentifyingastransgender.Descriptionsofbackingawayormovingfromtransgender-identifiedtonottransgender-identifiedincludethefollowing.Oneparentobserved,“Sheidentifiedastransforsixmonths…Nowbackatschool,sheisthinkingmaybeshe'snottrans.”Anotherparentoffered,“Mydaughter[identified]astransfromages13–16.Shegraduallydesistedasshedevelopedmoreinsightintowhosheis.”Oneparentdescribedthatafteroneyearofidentifyingastransgender,“basically,shechangedhermindonceshestoppedspendingtimewiththatparticulargroupoffriends.”Thedurationoftransgender-identificationoftheAYAswhowerestilltransgender-identifiedatthetimeofsurveywascomparedtothedurationofthosewhowerenolongertransgender-identifiedandthosewhoseemedtobebackingawayfromatransgender-identification(combined)byt-test.Thedifferencebetweenthesegroupswasstatisticallysignificant(p=.025),withat-valueof-2.25showingthatthosewhowerenolongertransgender-identifiedandbackingawayhadalongerdurationofidentification(mean=24.1months)andthosewhowerestilltransgender-identifiedhadashortermeanduration(mean=14.4months). Download: PPTPowerPointslidePNGlargerimageTIFForiginalimageTable12.Transitionstepsanddisposition. https://doi.org/10.1371/journal.pone.0202330.t012ToexplorethedifferencesbetweentheAYAswhohadexposuretosocialinfluence(friendgroup,internet/socialmedia,orboth)andAYAswhodidnothaveaclearexposuretosocialinfluence(neitheranddon’tknow),aseriesofchi-squaredcalculationswereperformedforselectedvariables.(SeeTable13.)StatisticallysignificantdifferenceswererevealedforAYAswithexposuretosocialinfluenceshavingworseoutcomesformentalwell-beingandparent-childrelationships,andgreaternumbersexhibitingdistrust,isolatingandanti-socialbehaviorsincluding:narrowedrangeofinterestsandhobbies,expressingthattheyonlytrustedinformationfromtransgendersources,tryingtoisolatethemselvesfromtheirfamily,losinginterestinactivitiesthatweren’tpredominantlywithtransgenderorLGBTIAparticipants,andtellingpeopleorpostingonsocialmediathattheirparentis“transphobic,”“abusive,”or“toxic”becausetheparentdoesn’tagreewiththechild’sassessmentofbeingtransgender.Althoughthedifferencesinadditionalisolatingandanti-socialbehaviorsdidnotreachstatisticalsignificance,thesebehaviorstrendedtowardshigherratesintheAYAswhowereexposedtosocialinfluenceandmayhavenotreachedsignificantlevelsduetosmallnumbers.NosignificantdifferenceforageofAYA(atannouncementorattimeofsurveycompletion)wasdetectedbetweengroupsbyaone-wayANOVA. Download: PPTPowerPointslidePNGlargerimageTIFForiginalimageTable13.chi-squaredcomparisonsforexposuretosocialinfluence(SI)vsnotexposuretosocialinfluence(NSI). https://doi.org/10.1371/journal.pone.0202330.t013 DiscussionThisresearchdescribesparentalreportsaboutasampleofAYAswhowouldnothavemetdiagnosticcriteriaforgenderdysphoriaduringtheirchildhoodbutdevelopedsignsofgenderdysphoriaduringadolescenceoryoungadulthood.ThestrongestsupportforconsideringthatthegenderdysphoriawasnewinadolescenceoryoungadulthoodistheparentalanswersforDSM5criteriaforchildhoodgenderdysphoria.Notonlywouldnoneofthesamplehavemetthresholdcriteria,thevastmajorityhadzeroindicators.Althoughonemightarguethatthreeoftheindicatorscouldplausiblybemissedbyaparent(A1,A7,andA8ifthechildhadnotexpressedtheseverbally),fiveoftheindicators(A2-6)arereadilyobservablebehaviorsandpreferencesthatwouldbedifficultforaparenttomiss.Sixindicators(includingA1)arerequiredforathresholddiagnosis.Thenonexistentandlownumbersofreadilyobservableindicatorsreportedinthemajorityofthissampledoesnotsupportascenarioinwhichgenderdysphoriawasalwayspresentbutwasonlyrecentlydisclosedtotheparents. Parentsreportedthatbeforetheonsetoftheirgenderdysphoria,manyoftheAYAshadbeendiagnosedwithatleastonementalhealthdisorderorneurodevelopmentaldisabilityandmanyhadexperiencedatraumaticorstressfulevent.Experiencingasexorgenderrelatedtraumawasnotuncommon,norwasexperiencingafamilystressor(suchasparentaldivorce,deathofaparent,oramentalhealthdisorderinasiblingorparent).Additionally,nearlyhalfweredescribedashavingengagedinself-harmpriortotheonsetoftheirgenderdysphoria.Inotherwords,manyoftheAYAsandtheirfamilieshadbeennavigatingmultiplechallengesandstressorsbeforegenderdysphoriaandtransgender-identificationbecamepartoftheirlives.Thiscontextcouldpossiblycontributetofrictionbetweenparentandchildandthesecomplex,overlappingdifficultiesaswellasexperiencesofsame-sexattractionmayalsobeinfluentialinthedevelopmentofatransgenderidentificationforsomeoftheseAYAs.Careshouldbetakennottooverstateorunderstatethecontextofpre-existingdiagnosesortraumainthispopulationastheywereabsentinapproximatelyonethirdandpresentinapproximatelytwothirdsofthesample. ThisresearchsampleofAYAsalsodiffersfromthegeneralpopulationinthatitispredominantlynatalfemale,white,andhasanover-representationofindividualswhoareacademicallygifted,non-heterosexual,andareoffspringofparentswithhigheducationalattainment[59–61].Thesexratiofavoringnatalfemalesisconsistentwithrecentchangesinthepopulationofindividualsseekingcareforgenderdysphoria.Genderclinicshavereportedsubstantialincreasesinreferralsforadolescentswithachangeinthesexratioofpatientsmovingfrompredominantlynatalmalesseekingcareforgenderdysphoriatopredominantlynatalfemales[26–28,62].Althoughincreasedvisibilityoftransgenderindividualsinthemediaandavailabilityofinformationonline,withapartialreductionofstigmamightexplainsomeoftheriseinthenumbersofadolescentspresentingforcare[27],itwouldnotdirectlyexplainwhytheinversionofthesexratiohasoccurredforadolescentsbutnotadultsorwhythereisanewphenomenonofnatalfemalesexperiencinglate-onsetandadolescent-onsetgenderdysphoria.TheunexpectedlyhighrateofacademicallygiftedAYAsmayberelatedtothehigheducationalattainmentoftheparentsandmaybeareflectionofparentswhoareonline,abletocompleteonlinesurveysandareabletoquestionandchallengecurrentnarrativesaboutgenderdysphoriaandtransition.TheremaybeotherunknownvariablesthatrenderacademicallygiftedAYAssusceptibletoadolescent-onsetandlate-onsetgenderdysphoria.Thehigherthanexpectedrateofnon-heterosexualorientationsoftheAYAs(priortoannouncementofatransgender-identity)maysuggestthatthedesiretobetheoppositesexcouldstemfromexperiencinghomophobiaasarecentstudyshowedthatbeingtherecipientofhomophobicnamecallingfromone’speerswasassociatedwithachangeingenderidentityforadolescents[63].Thepotentialrelationshipofexperiencedhomophobiaandthedevelopmentofarapidonsetofgenderdysphoriaduringadolescenceoryoungadulthoodasperceivedbyparentsdeservesfurtherstudy. Thissampleisdistinctivelydifferentthanwhatisdescribedinpreviousresearchaboutgenderdysphoriabecauseofthedistributionofcasesoccurringinfriendshipgroupswithmultipleindividualsidentifyingastransgender,thepreponderanceofadolescent(natal)females,theabsenceofchildhoodgenderdysphoria,andtheperceivedsuddennessofonset.Inthisstudy,parentalreportsoftransgenderidentificationdurationinAYAssuggestthatinsomecases(~8%inthisstudy)genderdysphoriaandtransgender-identificationmaybetemporary,andthatlongerobservationperiodsmaybeneededtoassesssuchchanges.Furtherresearchisneededtoverifytheseresults.Therehavebeenanecdotalreportsofadolescentswhodesistedapproximately9–36monthsaftershowingsignsofarapidonsetofgenderdysphoria,butlongitudinalresearchfollowingAYAswithgenderdysphoriawouldbenecessarytostudydesistancetrends.Althoughitisstillunknownwhethertransitioningenderdysphoricindividualsdecreases,increases,orfailstochangetheratesofattemptedorcompletedsuicides[64],thisstudydocumentsAYAsusingasuicidenarrativeaspartoftheirargumentstoparentsanddoctorstowardsreceivingsupportandtransitionservices.DespitethepossibilitythattheAYAsareusingasuicidenarrativetomanipulateothers,itiscriticalthatanysuicidethreat,ideationorconcernistakenseriouslyandtheindividualshouldbeevaluatedimmediatelybyamentalhealthprofessional. Themajorityofparentswerereasonablysureorcertainthattheirchildmisrepresentedoromittedkeypartsoftheirhistorytotheirtherapistsandphysicians.Insomecases,themisrepresentationofone’shistorymaysimplybeadeliberateactbyapersonwhoisconvincedthattransitionistheonlywaythattheywillfeelbetterandwhomayhavebeencoachedthatlyingistheonlywaytogetwhattheythinktheyneed.Forothers,themisrepresentationmaynotbeaconsciousact.Thecreationofanalternateversionofone’schildhoodthatconformstoastoryofalwaysknowingonewastransgenderandthatisinsharpcontrasttothechildhoodthatwasobservedbythirdpartiesraisesthequestionofwhethertherehasbeenthecreationoffalsechildhoodmemoriesaspartof,oroutsideof,thetherapyprocess.Respondentaccountsofclinicianswhoignoredordisregardedinformation(suchasmentalhealthsymptomsanddiagnoses,medicalandtraumahistories)thatdidnotsupporttheconclusionthatthepatientwastransgender,suggeststhepossibilityofmotivatedreasoningandconfirmatorybiasesonthepartofclinicians.Inthe1990s,thebeliefsandpracticesofmanymentalhealthprofessionalsmayhavecontributedtotheirpatients’creationoffalsechildhoodmemoriesconsistentwithachildsexualabusenarrativeandresearchsincethenhasshownthatfalsechildhoodmemoriesofmundaneeventscanbeimplantedinlaboratorysettings[65–67].Itmaybeworthwhiletoexploreif,intoday’sculture,theremightbebeliefsandpracticesofsomementalhealthprofessionalsthatarecontributingtotheirpatients’creationoffalsechildhoodmemoriesconsistentwithan“alwaysknew/alwaysweretransgender”narrative. Emerginghypotheses Hypothesis1:Socialinfluencescancontributetothedevelopmentofgenderdysphoria Itisunlikelythatfriendsandtheinternetcanmakepeopletransgender.However,itisplausiblethatthefollowingcanbeinitiated,magnified,spread,andmaintainedviathemechanismsofsocialandpeercontagion:(1)thebeliefthatnon-specificsymptoms(includingthesymptomsassociatedwithtrauma,symptomsofpsychiatricproblems,andsymptomsthatarepartofnormalpuberty)shouldbeperceivedasgenderdysphoriaandtheirpresenceasproofofbeingtransgender;2)thebeliefthattheonlypathtohappinessistransition;and3)thebeliefthatanyonewhodisagreeswiththeself-assessmentofbeingtransgenderortheplanfortransitionistransphobic,abusive,andshouldbecutoutofone’slife.ThespreadofthesebeliefscouldallowvulnerableAYAstomisinterprettheiremotions,incorrectlybelievethemselvestobetransgenderandinneedoftransition,andtheninappropriatelyrejectallinformationthatiscontrarytothesebeliefs.Inotherwords,“genderdysphoria”maybeusedasacatch-allexplanationforanykindofdistress,psychologicalpain,anddiscomfortthatanAYAisfeelingwhiletransitionisbeingpromotedasacure-allsolution. Oneofthemostcompellingfindingssupportingapotentialroleofsocialandpeercontagioninthedevelopmentorexpressionofarapidonsetofgenderdysphoriaistheclustersoftransgender-identificationoccurringwithinfriendshipgroups.Theexpectedprevalenceoftransgenderyoungadultindividualsis0.7%[8].Yet,accordingtotheparentalreports,morethanathirdofthefriendshipgroupsdescribedinthisstudyhad50%ormoreoftheAYAsinthegroupbecomingtransgender-identifiedinasimilartimeframe.Thissuggestsalocalizedincreasetomorethan70timestheexpectedprevalencerate.Thisisanobservationthatdemandsurgentfurtherinvestigation.Onemightarguethathighratesoftransgender-identifiedindividualswithinfriendgroupsmaybesecondarytotheprocessoffriendselection:choosingtransgender-identifiedfriendsdeliberatelyratherthantheresultofgroupdynamicsandobservedcopingstylescontributingtomultipleindividuals,inasimilartimeframe,startingtointerprettheirfeelingsasconsistentwithbeingtransgender.Moreresearchwillbeneededtofinelydelineatethetimingoffriendgroupformationandthetimingandpatternofeachnewdeclarationoftransgender-identification.Althoughfriendselectionmayplayaroleinthesehighpercentagesoftransgender-identifyingmembersinfriendgroups,thedescribedpatternofmultiplefriends(andoftenthemajorityofthefriendsinthefriendgroup)becomingtransgender-identifiedinasimilartimeframesuggeststhattheremaybemorethanjustfriendselectionbehindtheseelevatedpercentages. Therearemanyinsightsfromourunderstandingofpeercontagionineatingdisordersandanorexiathatmayapplytothepotentialrole(s)ofpeercontagioninthedevelopmentofgenderdysphoria.Justasfriendshipcliquescansetthelevelofpreoccupationwithone’sbody,bodyimage,weight,andtechniquesforweightloss[37–39],sotoomayfriendshipcliquessetalevelofpreoccupationwithone’sbody,bodyimage,gender,andthetechniquestotransition.Thedescriptionsofpro-anorexiasubculturegroupdynamicswherethethinnestanorexicsareadmiredwhiletheanorexicswhotrytorecoverfromanorexiaareridiculedandmalignedasoutsiders[39–41]resemblethegroupdynamicsinfriendgroupsthatvalidatethosewhoidentifyastransgenderandmockthosewhodonot.Andthepro-eating-disorderwebsitesandonlinecommunitiesprovidinginspirationforweightlossandsharingtrickstohelpindividualsdeceiveparentsanddoctors[42–44]maybeanalogoustotheinspirationalYouTubetransitionvideosandthesharedonlineadviceaboutmanipulatingparentsanddoctorstoobtainhormones. Hypothesis2:Parentalconflictmightprovidealternativeexplanationsforselectedfindings ParentsreportedsubjectivedeclinesintheirAYAs’mentalhealthandinparent-childrelationshipsafterthechildrendisclosedatransgenderidentification.Additionally,perparentreport,almosthalfoftheAYAswithdrewfromfamily,28.5%refusedtospeaktoaparent,and6.8%triedtorunaway.Itispossiblethatsomeofthesefindingsmightbesecondarytoparent-childconflict.Parent-childconflictcouldarisefromdisagreementoverthechild’sself-assessmentofbeingtransgender.Itisalsopossiblethatsomeparentsmighthavehaddifficultycopingorcouldhavebeencopingpoorlyormaladaptivelywiththeirchild’sdisclosure.OtherpotentialexplanationsfortheabovefindingsincludeworseningofAYAs’pre-existing(oronsetofnew)psychiatricconditionsortheuseofmaladaptivecopingmechanisms.Tofurtherevaluatethesepossibilities,futurestudiesshouldincorporateinformationaboutfamilydynamics,parent-childinteractions,parentcoping,childcoping,andpsychiatrictrajectories.Thisstudydidnotcollectdataabouttheparents’baselinecopingstyles,howtheywerecopingwiththeirchild’sdisclosure,andwhethertheircopingseemedtobemaladaptiveoradaptive.Nordiditexploreparents’mentalwell-being.Futurestudiesshouldexploretheseissuesaswell. Althoughmostparentsreportedanabsenceofchildhoodindicatorsforgenderdysphoria,itispossiblethattheseindicatorsmighthaveexistedforsomeoftheAYAsandthatsomeparentseitherfailedtonoticeorignoredtheseindicatorswhentheyoccurred.Becausethereadilyobservableindicatorscouldalsohavebeenobservedbyotherpeopleinthechild’slife,futurestudiesshouldincludeinputfromparents,AYAsandfromthirdpartyinformantssuchasteachers,pediatricians,mentalhealthprofessionals,babysitters,andotherfamilymemberstoverifythepresenceorabsenceofreadilyobservablebehaviorsandpreferencesduringchildhood.Parentalapproachestotheirchild’sgenderdysphoriamightcontributetospecificoutcomes.Thisstudydidnotspecificallyexploreparentalapproachestogenderdysphoriaorparentalviewsonmedicalorsurgicalinterventions.Additionalstudiesthatexplorewhetherparentssupportordon’tsupport:genderexploration;gendernonconformity;non-heterosexualsexualidentities;mentalhealthevaluationandtreatment;andexplorationofpotentialunderlyingcausesfordysphoriawouldbeextremelyvaluable.Itwouldalsobeworthwhiletoexplorewhetherparentsfavoraffirmingthechildasapersonoraffirmingthechild’sgenderidentityandwhetherparentsholdliberal,cautious,ornegativeviewsabouttheuseofmedicalandsurgicalinterventionsforgenderdysphoriainAYAs. Hypothesis3:MaladaptivecopingmechanismsmayunderliethedevelopmentofgenderdysphoriaforsomeAYAs Forsomeindividuals,thedrivetotransitionmayrepresentanego-syntonicbutmaladaptivecopingmechanismtoavoidfeelingstrongornegativeemotionssimilartohowthedrivetoextremeweightlosscanserveasanego-syntonicbutmaladaptivecopingmechanisminanorexianervosa[68–69].Amaladaptivecopingmechanismisaresponsetoastressorthatmightrelievethesymptomstemporarilybutdoesnotaddressthecauseoftheproblemandmaycauseadditionalnegativeoutcomes.Examplesofmaladaptivecopingmechanismsincludetheuseofalcohol,drugs,orself-harmtodistractoneselffromexperiencingpainfulemotions.Onereasonthatthetreatmentofanorexianervosaissochallengingisthatthedriveforextremeweightlossandweightlossactivitiescanbecomeamaladaptivecopingmechanismthatallowsthepatienttoavoidfeelinganddealingwithstrongemotions[69–70].Inthiscontext,dietingisnotfeltasdistressingtothepatient,becauseitisconsideredbythepatienttobethesolutiontoherproblems,andnotpartoftheproblems.Inotherwords,thedietingandweightlossactivitiesareego-syntonictothepatient.However,distressisfeltbythepatientwhenexternalactors(doctors,parents,hospitalstaff)trytointerferewithherweightlossactivitiesthuscurtailinghermaladaptivecopingmechanism. FindingsthatmaysupportamaladaptivecopingmechanismhypothesisincludethatthemostlikelydescriptionofAYAabilitytousenegativeemotionsproductivelywaspoor/extremelypoorandthemajorityofAYAsweredescribedas“overwhelmedbystrongemotionsandtriesto/goestogreatlengthstoavoidexperiencingthem.”Althoughthesearenotvalidatedquestions,thefindingssuggest,atleast,thatthereisahistoryofdifficultydealingwithemotions.ThehighfrequencyofparentsreportingAYAexpectationsthattransitionwouldsolvetheirproblemscoupledwiththesizableminoritywhoreportedAYAunwillingnesstoworkonbasicmentalhealthissuesbeforeseekingtreatmentsupporttheconceptthatthedrivetotransitionmightbeusedtoavoiddealingwithmentalhealthissuesandaversiveemotions.AdditionalsupportforthishypothesisisthatthesampleofAYAsdescribedinthisstudyarepredominantlyfemale,weredescribedbyparentsasbeginningtoexpresssymptomsduringadolescenceandcontainedanoverrepresentationofacademicallygiftedstudentswhichbearsastrongresemblancetopopulationsofindividualsdiagnosedwithanorexianervosa[71–75].Theriskfactors,mechanismsandmeaningsofanorexianervosa[69–70,76]mayultimatelyprovetobeavaluabletemplatetounderstandtheriskfactors,mechanisms,andmeaningsforsomecasesofgenderdysphoria. Transitionasadrivetoescapeone’sgender/sex,emotions,ordifficultrealitiesmightalsobeconsideredwhenthedrivetotransitionarisesafterasexorgender-relatedtraumaorwithinthecontextofsignificantpsychiatricsymptomsanddeclineinabilitytofunction.Althoughtraumaandpsychiatricdisordersarenotspecificforthedevelopmentofgenderdysphoria,theseexperiencesmayleaveapersoninpsychologicalpainandinsearchofacopingmechanism.Thefirstcopingmechanismthatavulnerablepersonadoptsmaybetheresultoftheirenvironmentandwhichnarrativesforpainandcopingaremostprevalentinthatenvironment—insomesettingsagenderdysphoria/drivetotransitionmaybethedominantparadigm,insomesettingsabodydysphoria/driveforextremeweightlossisdominant,andinanothertheuseofalcoholanddrugstocopewithpainmaybedominant.Becausemaladaptivecopingmechanismsdonotaddresstherootcauseofdistressandmaycausetheirownnegativeconsequences,anoutcomecommonlyreportedforthissample,AYAsexperiencingadeclineintheirmentalwell-beingaftertransgender-identification,isconsistentwiththishypothesis.TherewasasubsetofAYAsforwhomparentsreportedimprovementintheirmentalwell-beingastheydesistedfromtheirtransgender-identificationwhichwouldnotbeinconsistentwithmovingfromamaladaptivecopingmechanismtoanadaptivecopingmechanism. Iftheabovehypothesesarecorrect,rapidonsetofgenderdysphoriathatissociallymediatedand/orusedasamaladaptivecopingmechanismmaybeharmfultoAYAsinthefollowingways:(1)non-treatmentordelayedtreatmentfortraumaandmentalhealthproblemsthatmightbetherootof(oratleastaninherentpartof)theAYAs’issues;(2)alienationoftheAYAsfromtheirparentsandothercrucialsocialsupportsystems;(3)isolationfrommainstream,non-transgendersociety,whichmaycurtaileducationalandvocationalpotential;and(4)theassumptionofthemedicalandsurgicalrisksoftransitionwithoutbenefit.Inadditiontotheseindirectharms,thereisalsothepossibilitythatthistypeofgenderdysphoria,withthesubsequentdrivetotransition,mayrepresentaformofintentionalself-harm.Promotingtheaffirmationofadeclaredgenderandrecommendingtransition(social,medical,surgical)withoutevaluationmayaddtotheharmfortheseindividualsasitcanreinforcethemaladaptivecopingmechanism,prolongthelengthoftimebeforetheAYAacceptstreatmentfortraumaormentalhealthissues,andinterferewiththedevelopmentofhealthy,adaptivecopingmechanisms.Itisespeciallycriticaltodifferentiateindividualswhowouldbenefitfromtransitionfromthosewhowouldbeharmedbytransitionbeforeproceedingwithtreatment. ReflectionsCliniciansneedtobeawareofthemyriadofbarriersthatmaystandinthewayofmakingaccuratediagnoseswhenanAYApresentswithadesiretotransitionincluding:thedevelopmentalstageofadolescence;thepresenceofsubculturescoachingAYAstomisleadtheirdoctors;andtheexclusionofparentsfromtheevaluation.Inthisstudy,22.3%ofAYAswerereportedashavingbeenexposedtoonlineadviceaboutwhattosaytodoctorstogethormones,and17.5%totheadvicethatitisacceptabletolietophysicians;andthevastmajorityofparentswerereasonablysureorpositivethattheirchildmisrepresentedtheirhistorytotheirdoctorortherapist.Furthermore,althoughparentsmaybeknowledgeableinformantsonmattersoftheirownchild’sdevelopmental,medical,social,behavioral,andmentalhealthhistory-andquitepossiblybecausetheyareknowledgeable-theyareoftenexcludedfromtheclinicaldiscussionbytheAYAs,themselves.AnAYAtellingtheirclinicianthattheirparentsaretransphobicandabusivemayindeedmeanthattheparentsaretransphobicandabusive.However,thefindingsofthisresearchindicatethatitisalsopossiblethattheAYAcallstheparenttransphobicandabusivebecausetheparentdisagreeswiththechild’sself-diagnosis,hasexpressedconcernforthechild’sfuture,orhasrequestedthatthechildbeevaluatedformentalhealthissuesbeforeproceedingwithtreatment. Thefindingsofthisstudysuggestthatcliniciansneedtobecautiousbeforerelyingsolelyonself-reportwhenAYAsseeksocial,medicalorsurgicaltransition.Adolescentsandyoungadultsarenottrainedmedicalprofessionals.WhenAYAsdiagnosetheirownsymptomsbasedonwhattheyreadontheinternetandhearfromtheirfriends,itisquitepossibleforthemtoreachincorrectconclusions.Itisthedutyoftheclinician,whenseeinganewAYApatientseekingtransition,toperformtheirownevaluationanddifferentialdiagnosistodetermineifthepatientiscorrectorincorrectintheirself-assessmentoftheirsymptomsandtheirconvictionthattheywouldbenefitfromtransition.Thisisnottosaythattheconvictionsofthepatientshouldbedismissedorignored,somemayultimatelybenefitfromtransition.However,carefulclinicalexplorationshouldnotbeneglected,either.Thepatient’shistorybeingsignificantlydifferentthantheirparents’accountofthechild’shistoryshouldserveasaredflagthatamorethoroughevaluationisneededandthatasmuchaspossibleaboutthepatient’shistoryshouldbeverifiedbyothersources.Thefindingsthatthemajorityofcliniciansdescribedinthisstudydidnotexploretraumaormentalhealthdisordersaspossiblecausesofgenderdysphoriaorrequestmedicalrecordsinpatientswithatypicalpresentationsofgenderdysphoriaisalarming.Thereportedbehaviorofcliniciansrefusingtocommunicatewiththeirpatients’parents,primarycarephysicians,andpsychiatristsbetraysaresistancetotriangulationofevidencewhichputsAYAsatconsiderablerisk. Itispossiblethatsometeensandyoungadultsmayhaverequestedthattheirdiscussionswiththecliniciansaddressinggenderissuesbekeptconfidentialfromtheirparents,asistheirright(exceptforinformationthatwouldputthemselvesorothersatharm).However,maintainingconfidentialityofthepatientdoesnotpreventtheclinicianfromlisteningtothemedicalandsocialhistoryofthepatientprovidedbytheparent.Nordoesitpreventaclinicianfromacceptinginformationprovidedbythepatient’sprimarycarephysiciansandpsychiatrists.Becauseadolescentsmaynotbereliablehistoriansandmayhavelimitedawarenessandinsightabouttheirownemotionsandbehaviors,theinclusionofinformationfrommultipleinformantsisoftenrecommendedwhenworkingwithorevaluatingminors.Onewouldexpectthatifapatientrefusestheinclusionofinformationfromparentsandphysicians(priorandcurrent),thattheclinicianwouldexplorethiswiththepatientandencouragethemtoreconsider.Attheveryleast,ifapatientasksthatallinformationfromparentsandmedicalsourcesbedisregarded,itshouldraisethesuspicionthatwhatthepatientispresentingmaybelessthanforthcomingandtheclinicianshouldproceedwithcaution. TheargumenttosurfacefromthisstudyisnotthattheinsiderperspectivesofAYAspresentingwithsignsofarapidonsetofgenderdysphoriashouldbesetasidebyclinicians,butthattheinsightsofparentsareapre-requisiteforrobusttriangulationofevidenceandfullyinformeddiagnosis.Allparentsknowtheirgrowingchildrenarenotalwaysright,particularlyinthealmostuniversallytumultuousperiodofadolescence.Mostparentshavetheawarenessandhumilitytoknowthatevenasadultstheyarenotalwaysrightthemselves.WhenanAYApresentswithsignsofarapidonsetofgenderdysphoriaitisincumbentuponallprofessionalstofullyrespecttheyoungperson’sinsiderperspectivebutalso,intheinterestsofsafediagnosisandavoidanceofclinicalharm,tohavetheawarenessandhumilitythemselvestoengagewithparentalperspectivesandtriangulateevidenceintheinterestofvalidityandreliability. Thestrengthsofthisstudyincludethatitisthefirstempiricaldescriptionofaspecificphenomenonthathasbeenobservedbyparentsandclinicians[14]andthatitexploresparentobservationsofthepsychosocialcontextofyouthwhohaverecentlyidentifiedastransgenderwithafocusonvulnerabilities,co-morbidities,peergroupinteractions,andsocialmediause.Additionally,thequalitativeanalysisofresponsesaboutpeergroupdynamicsprovidesarichillustrationofAYAintra-groupandinter-groupbehaviorsasobservedandreportedbyparents.ThisresearchalsoprovidesaglimpseintoparentperceptionsofclinicianinteractionsintheevaluationandtreatmentofAYAswithanadolescent-onset(oryoungadult-onset)ofgenderdysphoriasymptoms. Thelimitationsofthisstudyincludethatitisadescriptivestudyandthushastheknownlimitationsinherentinalldescriptivestudies.Thisisnotaprevalencestudyanddoesnotattempttoevaluatetheprevalenceofgenderdysphoriainadolescentsandyoungadultswhohadnotexhibitedchildhoodsymptoms.Likewise,thisstudy’sfindingsdidnotdemonstratethedegreetowhichtheonsetofgenderdysphoriasymptomsmaybesociallymediatedorassociatedwithamaladaptivecopingmechanism,althoughthesehypotheseswerediscussedhere.Gatheringmoredataonthetopicsintroducedisakeyrecommendationforfurtherstudy.Itisnotuncommonforfirst,descriptivestudies,especiallywhenstudyingapopulationorphenomenonwheretheprevalenceisunknown,tousetargetedrecruiting.Tomaximizethepossibilityoffindingcasesmeetingeligibilitycriteria,recruitmentisdirectedtowardscommunitiesthatarelikelytohaveeligibleparticipants.Forexample,inthefirstdescriptivestudyaboutchildrenwhohadbeensociallytransitioned,theauthorsrecruitedpotentialsubjectsfromgenderexpansivecampsandgenderconferenceswhereparentswhosupportedsocialtransitionforyoungchildrenmightbepresentandtheauthorsdidnotseekoutcommunitieswhereparentsmightbelessinclinedtofindsocialtransitionforyoungchildrenappropriate[77].Inthesameway,forthecurrentstudy,recruitmentwastargetedprimarilytositeswhereparentshaddescribedthephenomenonofarapidonsetofgenderdysphoriabecausethosemightbecommunitieswheresuchcasescouldbefound.Thegeneralizabilityofthestudymustbecarefullydelineatedbasedontherecruitmentmethods,and,likeallfirstdescriptivestudies,additionalstudieswillbeneededtoreplicatethefindings. Threeofthesitesthatpostedrecruitmentinformationexpressedcautiousornegativeviewsaboutmedicalandsurgicalinterventionsforgenderdysphoricadolescentsandyoungadultsandcautiousornegativeviewsaboutcategorizinggenderdysphoricyouthastransgender.Oneofthesitesthatpostedrecruitmentinformationisperceivedtobepro-gender-affirming.Hence,thepopulationsviewingthesewebsitesmightholddifferentviewsorbeliefsfromeachother.Andbothpopulationsmaydifferfromabroadergeneralpopulationintheirattitudesabouttransgender-identifiedindividuals.Thisstudydidnotexplorespecificparticipantviewsaboutmedicalandsurgicalinterventionsforgenderdysphoricyouthorwhetherparticipantssupportordon’tsupport:explorationofgenderidentity,explorationofpotentialunderlyingcausesforgenderdysphoria,affirmationofchildrenasvaluedindividualsoraffirmationofchildren’sgenderidentity.Futurestudiesshouldexplorealltheseissues.Thisstudycannotspeaktothosedetailsabouttheparticipants. Respondentswereasked,“Doyoubelievethattransgenderpeopledeservethesamerightsandprotectionsasothersinyourcountry?”whichisaquestionthatwasadaptedfromaquestionusedforaUSnationalpoll[78].Althoughthisquestioncannotelicitspecificdetailsaboutapersons’beliefsaboutmedicalinterventions,beliefsabouttransgenderidentification,ortheirbeliefsabouttheirownchild,itcanbeusedtoassessiftheparticipantsinthisstudyaresimilarintheirbasicbeliefsabouttherightsoftransgenderpeopletotheparticipantsintheUSnationalpoll.Themajority(88.2%)ofthestudyparticipantsgaveaffirmativeanswerstothequestionwhichisconsistentwiththe89%affirmativeresponsereportedinaUSnationalpoll[78].Allself-reportedresultshavethepotentiallimitationofsocialdesirabilitybias.However,comparingthisself-reportsampletothenationalself-reportsample[78],theresultsshowsimilarratesofsupport.Therefore,thereisnoevidencethatthestudysampleisappreciablydifferentintheirsupportoftherightsoftransgenderpeoplethanthegeneralAmericanpopulation.Itisalsoimportanttonotethatrecruitmentwasnotlimitedtothewebsiteswheretheinformationaboutthestudywasfirstposted.Snowballsamplingwasalsousedsothatanypersonviewingtherecruitmentinformationwasencouragedtosharetheinformationwithanypersonorcommunitywheretheythoughttherecouldbepotentiallyeligibleparticipants,thussubstantiallywideningthereachofpotentialrespondents.Infollowupstudiesonthistopic,anevenwidervarietyofrecruitmentsourcesshouldbeattempted. Anotherlimitationofthisstudyisthatitincludedonlyparentalperspective.Ideally,datawouldbeobtainedfromboththeparentandthechildandtheabsenceofeitherperspectivepaintsanincompleteaccountofevents.Inputfromtheyouthwouldhaveyieldedadditionalinformation.Furtherresearchthatincludesdatacollectionfrombothparentandchildisrequiredtofullyunderstandthiscondition.However,becausethisresearchhasbeenproducedinaclimatewheretheinputfromparentsisoftenneglectedintheevaluationandtreatmentofgenderdysphoricAYAs,thisresearchsuppliesavaluable,previouslymissingpiecetothejigsawpuzzle.IfHypothesis3iscorrectthatforsomeAYAsgenderdysphoriarepresentsanego-syntonicmaladaptivecopingmechanism,datafromparentsareespeciallyimportantbecauseaffectedAYAsmaybesocommittedtothemaladaptivecopingmechanismthattheirabilitytoassesstheirownsituationmaybeimpaired.Furthermore,parentsuniquelycanprovidedetailsoftheirchild’searlydevelopmentandthepresenceorabsenceofreadilyobservablechildhoodindicatorsofgenderdysphoriaareespeciallyrelevanttothediagnosis.Thereare,however,obviouslimitationstorelyingsolelyonparentreport.ItispossiblethatsomeoftheparticipatingparentsmaynothavenoticedsymptomsofgenderdysphoriabeforetheirAYA’sdisclosureofatransgenderidentity;couldhavebeenexperiencingshock,grief,ordifficultycopingfromthedisclosure;orevencouldhavechosentodenyorobscureknowledgeoflongtermgenderdysphoria.Readersshouldholdthispossibilityinmind.Overall,the200plusresponsesappeartohavebeenpreparedcarefullyandwererichindetail,suggestingtheywerewritteningoodfaithandthatparentswereattentiveobserversoftheirchildren'slives.Althoughthisresearchaddsthenecessarycomponentofparentobservationtoourunderstandingofgenderdysphoricadolescentsandyoungadults,futurestudyinthisareashouldincludebothparentandchildinput. ThisresearchdoesnotimplythatnoAYAswhobecometransgender-identifiedduringtheiradolescentoryoungadultyearshadearliersymptomsnordoesitimplythatnoAYAswouldultimatelybenefitfromtransition.Rather,thefindingssuggestthatnotallAYAspresentingatthesevulnerableagesarecorrectintheirself-assessmentofthecauseoftheirsymptomsandsomeAYAsmaybeemployingadrivetotransitionasamaladaptivecopingmechanism.ItmaybedifficulttodistinguishifanAYA’sdecliningmentalhealthisoccurringduetotheuseofamaladaptivecopingmechanism,duetotheworseningofapre-existing(oronsetofanew)psychiatriccondition,orduetoconflictwithparents.Cliniciansshouldcarefullyexploretheseoptionsandtrytoclarifyareasofdisagreementwithconfirmationfromoutsidesourcessuchasmedicalrecords,psychiatrists,psychologists,primarycarephysicians,andotherthirdpartyinformantswherepossible.Furtherstudyofmaladaptivecopingmechanisms,psychiatricconditionsandfamilydynamicsinthecontextofgenderdysphoriaandmentalhealthwouldbeanespeciallyvaluablecontributiontobetterunderstandhowtotreatyouthwithgenderdysphoria. Moreresearchisneededtodeterminetheincidence,prevalence,persistenceanddesistencerates,andthedurationofgenderdysphoriaforadolescent-onsetgenderdysphoriaandtoexaminewhetherrapid-onsetgenderdysphoriaisadistinctand/orclinicallyvalidsubcategoryofgenderdysphoria.Adolescent-onsetgenderdysphoriaissufficientlydifferentfromearly-onsetofgenderdysphoriathatpersistsorworsensatpubertyandtherefore,theresearchresultsfromearly-onsetgenderdysphoriashouldnotbeconsideredgeneralizabletoadolescent-onsetgenderdysphoria.Itiscurrentlyunknownwhetherthegenderdysphoriasofadolescent-onsetgenderdysphoriaandoflate-onsetgenderdysphoriaoccurringinyoungadultsaretransient,temporaryorlikelytobelong-term.Withouttheknowledgeofwhetherthegenderdysphoriaislikelytobetemporary,extremecautionshouldbeappliedbeforeconsideringtheuseoftreatmentsthathavepermanenteffectssuchascross-sexhormonesandsurgery.Researchneedstobedonetodetermineifaffirminganewlydeclaredgenderidentity,socialtransition,pubertysuppressionandcross-sexhormonescancauseaniatrogenicpersistenceofgenderdysphoriainindividualswhowouldhavehadtheirgenderdysphoriaresolveonitsownandwhethertheseinterventionsprolongthedurationoftimethatanindividualfeelsgenderdysphoricbeforedesisting.Thereisalsoaneedtodiscoverhowtodiagnosetheseconditions,howtotreattheAYAsaffected,andhowbesttosupportAYAsandtheirfamilies.Additionally,analysesofonlinecontentforpro-transitionsitesandsocialmediashouldbeconductedinthesamewaythatcontentanalysishasbeenperformedforpro-eatingdisorderwebsitesandsocialmediacontent[44].Finally,furtherexplorationisneededforpotentialcontributorstorecentdemographicchangesincludingthesubstantialincreaseinthenumberofadolescentnatalfemaleswithgenderdysphoriaandthenewphenomenonofnatalfemalesexperiencinglate-onsetoradolescent-onsetgenderdysphoria. ConclusionCollectingdatafromparentsinthisdescriptiveexploratorystudyhasprovidedvaluable,detailedinformationthatallowsforthegenerationofhypothesesaboutpotentialfactorscontributingtotheonsetandexpressionofgenderdysphoriaamongAYAs.Emerginghypothesesincludethepossibilityofapotentialnewsubcategoryofgenderdysphoria(referredtoasrapid-onsetgenderdysphoria)thathasnotyetbeenclinicallyvalidatedandthepossibilityofsocialinfluencesandmaladaptivecopingmechanismscontributingtothedevelopmentofgenderdysphoria.Parent-childconflictmayalsocontributetothecourseofthedysphoria.MoreresearchthatincludesdatacollectionfromAYAs,parents,cliniciansandthirdpartyinformantsisneededtofurtherexploretherolesofsocialinfluence,maladaptivecopingmechanisms,parentalapproaches,andfamilydynamicsinthedevelopmentanddurationofgenderdysphoriainadolescentsandyoungadults. SupportinginformationS1Appendix.Surveyinstrument.https://doi.org/10.1371/journal.pone.0202330.s001(PDF) S2Appendix.COREQchecklist.https://doi.org/10.1371/journal.pone.0202330.s002(PDF) Acknowledgments IwouldliketoacknowledgeMichaelL.Littman,PhD,forhisassistanceinthestatisticalanalysisofquantitativedata,MicheleMoore,PhD,forherassistanceinqualitativedataanalysisandfeedbackonanearlierversionofthemanuscript,LisaMarchiano,LCSW,forfeedbackonearlierversionsofthemanuscript,andfourexternalpeer-reviewers,threePLOSONEstaffeditorsandtwoAcademicEditorsfortheirattentiontothisresearch. 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