Gender Dysphoria Is Not Contagious

How an anti-trans study mischaracterized a real condition to shore up “rapid-onset gender dysphoria.”

Two trans men.
Photo illustration by Derreck Johnson. Photos by Ranta Images/iStock.

This post is part of Outward, Slate’s home for coverage of LGBTQ life, thought, and culture. Read more here.

On Aug. 16, Brown University’s Lisa Littman published a controversial study in the journal PLOS One looking at a hypothesized condition known on certain anti-trans websites as “rapid-onset gender dysphoria.” The study, which collected parental reports from individuals who frequent these websites, has been widely critiqued, and these criticisms eventually persuaded Brown to pull the paper from its website. PLOS One also announced that it would review the paper’s dubious methods. (Alex Barasch has written more on the study and its many methodical problems for Slate.)

But one aspect of the study that has seen little coverage is Littman’s uncredited use of the work of Zinnia Jones, a trans female writer who has reported on the possible connections between gender dysphoria and the psychiatric symptoms known as depersonalization and derealization. These symptoms consist of a feeling of disconnection from oneself or one’s life or that the outside world isn’t quite real. Littman’s paper cited a brief, out-of-context portion of Jones’ writing on depersonalization, describing her research on “vague and nonspecific symptoms” of gender dysphoria.

Littman was wrong to use this snippet of Jones’ work to bolster her questionable thesis. It is, however, notable that depersonalization—which has often been associated with trauma—may also have a connection to gender dysphoria. I spoke with Jones about her analysis of this link and about the importance of transgender people engaging with research that affects our lives and legitimacy. Our interview has been edited and condensed.

Evan Urquhart: Let’s talk about the connections between dissociative symptoms and gender dysphoria. These symptoms are ones you experienced firsthand as a trans woman before transitioning, right?

Zinnia Jones: Depersonalization symptoms were something I’d always experienced, and pretty intensely. I always assumed that this was normal. It turns out a lot of people with depersonalization disorder do make this assumption. There was a feeling of everything not being quite real, being stuck in my head, being an observer. I felt robotic, like I was only going through the motions, and disconnected from my body.

If Littman was looking for an example of vague and nonspecific symptoms, this would not be an example of that. When I ended up describing these symptoms in my original article, I didn’t even realize there was a name for this: depersonalization disorder.

When I started transitioning, particularly when I started hormone replacement therapy in 2012, the resolution of these symptoms came as a complete surprise to me. My goal had been to feminize my appearance and prevent any further masculinization. I had no idea about the emotional or mental effects, beyond just community folklore that you might start feeling better, or more alive, or as if you’re finally “running on the right fuel.”

Within the first week of starting hormones I started to feel alive in a way I’d never felt before. Things took on more depth and color. I stopped being stuck in my head, feeling cutoff, feeling robotic. I could be spontaneous. I could be in the moment.

Since then, I’ve seen a lot of people share this experience of “waking up” as well, often without knowing the specific words for it but describing strikingly similar phenomena, frequently using some of the very same phrases and metaphors. When trans people talk about how their lives only truly began once they transitioned, they are often being more literal than figurative.

Like you, I had similar symptoms that resolved when I began hormone therapy—in my case as a trans man, testosterone. Tell me a little bit about why it might make sense that untreated gender dysphoria manifests as feelings of depersonalization and derealization?

Practically speaking, almost every common psychiatric condition occurs at an elevated rate for people with gender dysphoria. We experience more depression, more anxiety, more suicidality, and so on. With dissociation, it’s entirely possible that a sense of alienation from one’s body physically, feeling that it doesn’t belong to you, would lead to these exact sensations.

Furthermore, this is highly speculative, but it’s also possible that there is a neurochemical effect of sex hormones that influences these dissociative symptoms directly. This is compatible with community reports of depersonalization symptoms remitting within days or weeks after starting HRT, far before any visible physical changes would become apparent. The current most-effective medications for depersonalization disorder in the general population focus on modulating serotonin and glutamate, with an action essentially opposite that of dissociative drugs. Estrogen, too, can potentially produce anti-dissociative effects by acting at glutamate receptors—both estrogen and other estrogenic compounds have been found to treat negative and cognitive symptoms of schizophrenia, one of which is depersonalization. So there are plenty of potential links between sex hormones and neurotransmitters involved in dissociative symptoms.

You’ve looked deeply into the research about the potential connections between dissociative symptoms and gender dysphoria. What does the research show?

I have a whole section on my website on the details on this. There’ve been at least half a dozen studies looking at dissociative symptoms in trans people.

One percent of the general population experiences depersonalization disorder, while 10 to 15 percent of trans people experience clinical levels of depersonalization (not counting other dissociative conditions and symptoms). These levels are often much lower after transition, and trans people who have undergone surgical transition generally have depersonalization symptoms at rates comparable to the general population and cisgender controls.

In 2015, two years after I wrote my original article, a study was published of dissociative conditions and symptoms in trans men and women before medical treatment, after starting HRT, and after undergoing surgery. It found depersonalization was elevated before treatment, with a significant drop after HRT, and no further drop after surgery.

How would you compare the state of research into connections between gender dysphoria and dissociative symptoms with the state of research into rapid-onset gender dysphoria?

Well, one advantage of the research on dissociative symptoms in trans people is that the patients themselves were studied, rather than only their parents, let alone parents recruited from a website characterized by its user base’s endless doubt of their relatives’ experiences of gender dysphoria [as was done in the ROGD study].

ROGD is an entirely new construct with a theoretically shaky basis and countless methodological flaws. Although much more research needs to be done on depersonalization, I’d say the science on this is already far more firmly established than anything relating to ROGD. It hasn’t even been established that ROGD is a distinct syndrome at all. Gender dysphoria is real, depersonalization disorder is real, and there’s clear evidence that there’s a link between the two.

Could you talk about how you approach your reporting, and why you do this work?

I would say that a cis perspective can omit a lot of crucial details and experiences that trans people are privy to in our own lives. We notice things that others may not. And too often, the task of critiquing certain cisgender theories of gender dysphoria falls to us: We do the work that others aren’t doing because if we don’t do it, it’s likely no one will. Just consider how the chief proponents of “rapid-onset gender dysphoria” have responded to my scientific criticism of the theory.

4thWaveNow, a community from which parents were recruited for [Littman’s] survey, has now spent several days tweeting about how PLOS One shouldn’t listen to my critique because I’m also a sex worker. This is unprofessional, inappropriate, and rude. Sexologist Ray Blanchard, who has promoted the ROGD theory on 4thWaveNow, has adopted a similar stance of slut shaming. And J. Michael Bailey, another sexologist and proponent of ROGD on 4thWaveNow, has told PLOS One that I have “no evident interest in reasonable scientific investigation.”

What they don’t seem to have realized is that this kind of behavior toward trans people undermines their contention that these communities are somehow a hub of accepting parents who would support a transgender child, adolescent, or adult. PLOS One invites continuing scientific review from the wider community after publication. The proponents of ROGD may not be interested in offering such review, but the trans community is more than ready to pick up the slack.

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