Rapid-onset gender dysphoria (ROGD) describes a phenomenon where the development of gender dysphoria is observed to begin suddenly during or after puberty in an adolescent or young adult who would not have met criteria for gender dysphoria in childhood. ROGD appears to represent an entity that is distinct from the gender dysphoria observed in individuals who have previously been described as transgender. The worsening of mental well-being and parent-child relationships and behaviors that isolate AYAs from their parents, families, non-transgender friends and mainstream sources of information are particularly concerning. More research is needed to better understand this phenomenon, its implications and scope.

There were 256 parent-completed surveys that met study criteria. The adolescent and young adult (AYA) children described were predominantly female sex at birth (82.8%) with a mean age of 16.4 years. Forty-one percent of the AYAs had expressed a non-heterosexual sexual orientation before identifying as transgender. Many (62.5%) of the AYAs had been diagnosed with at least one mental health disorder or neurodevelopmental disability prior to the onset of their gender dysphoria (range of the number of pre-existing diagnoses 0–7). In 36.8% of the friendship groups described, the majority of the members became transgender-identified. The most likely outcomes were that AYA mental well-being and parent-child relationships became worse since AYAs “came out”. AYAs expressed a range of behaviors that included: expressing distrust of non-transgender people (22.7%); stopping spending time with non-transgender friends (25.0%); trying to isolate themselves from their families (49.4%), and only trusting information about gender dysphoria from transgender sources (46.6%).

Recruitment information with a link to a 90-question survey, consisting of multiple-choice, Likert-type and open-ended questions, was placed on three websites where parents had reported rapid onsets of gender dysphoria. Website moderators and potential participants were encouraged to share the recruitment information and link to the survey with any individuals or communities that they thought might include eligible participants to expand the reach of the project through snowball sampling techniques. Data were collected anonymously via SurveyMonkey. Quantitative findings are presented as frequencies, percentages, ranges, means and/or medians. Open-ended responses from two questions were targeted for qualitative analysis of themes.

In on-line forums, parents have been reporting that their children are experiencing what is described here as “rapid-onset gender dysphoria,” appearing for the first time during puberty or even after its completion. The onset of gender dysphoria seemed to occur in the context of belonging to a peer group where one, multiple, or even all of the friends have become gender dysphoric and transgender-identified during the same timeframe. Parents also report that their children exhibited an increase in social media/internet use prior to disclosure of a transgender identity. The purpose of this study was to document and explore these observations and describe the resulting presentation of gender dysphoria, which is inconsistent with existing research literature.

Data Availability: The data cannot be made publicly available due to ethical restrictions. The study participants did not provide consent to have their responses shared publicly, shared in public databases, or shared with outside researchers. Furthermore, due to the sensitive information contained in the data and the politicized and contentious discourse around the study of gender dysphoria, protection of the privacy of the participants responding to the survey is of utmost importance. For any questions about restriction on data sharing, please contact the Program for the Protection of Human Subjects (PPHS) at the Icahn School of Medicine at Mount Sinai ( IRB@mssm.edu ).

Rapid presentation of adolescent-onset gender dysphoria and gender dysphoria cases occurring in clusters of pre-existing friend groups is not consistent with current knowledge about gender dysphoria and has not been described in the scientific literature to date. The purpose of this research is (1) to describe an atypical presentation of gender dysphoria occurring with sudden and rapid onset in adolescents and young adults; and (2) to generate hypotheses about the condition, including the role of social and peer contagion in its development.

In the past decade, there has been an increase in visibility, social media, and user-generated online content about transgender issues and transition [ 36 ], which may act as a double-edged sword. On the one hand, an increase in visibility has given a voice to individuals who would have been under-diagnosed and undertreated in the past [ 36 ]. On the other hand, it is plausible that online content may encourage vulnerable individuals to believe that nonspecific symptoms and vague feelings should be interpreted as gender dysphoria stemming from a transgender condition. Recently, leading international academic and clinical commentators have raised the question about the role of social media and online content in the development of gender dysphoria [ 37 ]. Concern has been raised that adolescents may come to believe that transition is the only solution to their individual situations, that exposure to internet content that is uncritically positive about transition may intensify these beliefs, and that those teens may pressure doctors for immediate medical treatment [ 18 ]. There are many examples on popular sites such as Reddit ( www.reddit.com with subreddit ask/r/transgender) and Tumblr ( www.tumblr.com ) where online advice promotes the idea that nonspecific symptoms should be considered to be gender dysphoria, conveys an urgency to transition, and instructs individuals how to deceive parents, doctors, and therapists to obtain hormones quickly [ 38 ]. Fig 1 includes examples of online advice from reddit and tumblr.

Peer contagion has been shown to be a factor in several aspects of eating disorders. There are examples in the eating disorder and anorexia nervosa literature of how both internalizing symptoms and behaviors have been shared and spread via peer influences [ 28 – 32 ] which may have relevance to considerations of rapid-onset gender dysphoria. Friendship cliques can set the norms for preoccupation with one’s body, one’s body image, and techniques for weight loss, and can predict an individual’s body image concerns and eating behaviors [ 28 – 30 ]. Peer influence is intensified in inpatient and outpatient treatment settings for patients with anorexia and counter-therapeutic subcultures that actively promote the beliefs and behaviors of anorexia nervosa have been observed [ 30 – 32 ]. In these settings, there is a group dynamic where the “best” anorexics (those who are thinnest, most resistant to gaining weight, and who have experienced the most medical complications from their disease) are admired, validated, and seen as authentic while the patients who want to recover from anorexia and cooperate with medical treatment are maligned, ridiculed, and marginalized [ 30 – 32 ]. Additionally, behaviors associated with deceiving parents and doctors about eating and weight loss, referred to as the “anorexic tricks,” are shared by patients in a manner akin to deviancy training [ 30 – 32 ]. Online environments provide ample opportunity for excessive reassurance seeking, co-rumination, positive and negative feedback, and deviancy training from peers who subscribe to unhealthy, self-harming behaviors. The pro-eating disorder sites provide motivation for extreme weight loss (sometimes calling the motivational content “thinspiration”). Such sites promote validation of eating disorder as an identity, and offer “tips and tricks” for weight loss and for deceiving parents and doctors so that individuals may continue their weight-loss activities [ 33 – 35 ]. If similar mechanisms are at work in the context of gender dysphoria, this greatly complicates the evaluation and treatment of impacted AYAs.

The description of cluster outbreaks of gender dysphoria occurring in pre-existing groups of friends and increased exposure to social media/internet preceding a child’s announcement of a transgender identity raises the possibility of social and peer contagion. Social contagion [ 20 ] is the spread of affect or behaviors through a population. Peer contagion, in particular, is the process where an individual and peer mutually influence each other in a way that promotes emotions and behaviors that can potentially undermine their own development or harm others [ 21 ]. Peer contagion has been associated with depressive symptoms, disordered eating, aggression, bullying, and drug use [ 21 , 22 ]. Internalizing symptoms such as depression can be spread via the mechanisms of co-rumination, which entails the repetitive discussion of problems, excessive reassurance seeking (ERS), and negative feedback [ 21 , 23 – 25 ]. Deviancy training, which was first described for rule breaking, delinquency, and aggression, is the process whereby attitudes and behaviors associated with problem behaviors are promoted with positive reinforcement by peers [ 26 , 27 ].

As recently as 2012, there were only two clinics (one in Canada and one in the Netherlands) that had gathered enough data to provide empirical information about the main issues for gender dysphoric adolescents [ 18 ]. Both institutions concluded that the management of adolescent-onset gender dysphoria is more complicated than the management of early-onset gender dysphoria and that individuals with adolescent-onset are more likely to have significant psychopathology [ 18 ]. The presentation of gender dysphoria can occur in the context of severe psychiatric disorders, developmental difficulties, or as part of large-scale identity issues and, for these patients, medical transition might not be advisable [ 19 ]. The APA Task Force on the Treatment of Gender Identity Disorder notes that adolescents with gender dysphoria “should be screened carefully to detect the emergence of the desire for sex reassignment in the context of trauma as well as for any disorder (such as schizophrenia, mania, psychotic depression) that may produce gender confusion. When present, such psychopathology must be addressed and taken into account prior to assisting the adolescent’s decision as to whether or not to pursue sex reassignment or actually assisting the adolescent with the gender transition.” [ 18 ].

Gender dysphoria (GD) is defined as an individual's persistent discomfort with their biological sex or assigned gender [ 6 ]. Two types of gender dysphoria studied include early-onset GD, where the symptoms of gender dysphoria begin in early childhood, and late-onset GD where the symptoms begin after puberty [ 6 ]. Late-onset GD that occurs during adolescence is now called adolescent-onset GD. The majority of adolescents who present for care for gender dysphoria are individuals who experienced early-onset gender dysphoria that persisted or worsened with puberty although an atypical presentation has been described where adolescents who did not experience childhood symptoms present with new symptoms in adolescence [ 2 , 7 ]. Adolescent-onset of gender dysphoria is a relatively new phenomenon for natal females. In fact, prior to 2012, there were no little to no research studies about adolescent females with gender dysphoria first beginning in adolescence [ 5 ]. Thus, far more is known about adolescents with early-onset gender dysphoria than adolescents with adolescent-onset gender dysphoria [ 1 , 8 ]. Although not all research studies on gender dysphoric adolescents exclude those with adolescent-onset gender dysphoria [ 5 ], it is important to note that most of the studies on adolescents, particularly those about gender dysphoria persistence and desistance rates and outcomes for the use of puberty suppression, cross-sex hormones, and surgery only included subjects whose gender dysphoria began in childhood and subjects with adolescent-onset gender dysphoria would not have met inclusion criteria for these studies [ 9 – 17 ]. Therefore, most of the research on adolescents with gender dysphoria to date is not generalizable to adolescents experiencing adolescent-onset gender dysphoria [ 9 – 17 ] and the outcomes for individuals with adolescent-onset gender dysphoria, including persistence and desistence rates and outcomes for treatments, are currently unknown.

In recent years, a number of parents have been reporting in online discussion groups such as 4thwavenow in the US ( https://4thwavenow.com ) and Transgender Trend in the UK ( https://www.transgendertrend.com ) that their adolescent and young adult (AYA) children, who have had no histories of childhood gender identity issues, experienced a rapid onset of gender dysphoria. Parents have described clusters of gender dysphoria outbreaks occurring in pre-existing friend groups with multiple or even all members of a friend group becoming gender dysphoric and transgender-identified in a pattern that seems statistically unlikely based on previous research [ 1 – 5 ]. Parents describe a process of immersion in social media, such as “binge-watching” Youtube transition videos and excessive use of Tumblr, immediately preceding their child becoming gender dysphoric. These descriptions are atypical for the presentation of gender dysphoria described in the research literature [ 1 – 5 ] and raise the question of whether social influences may be contributing to or even driving these occurrences of gender dysphoria in some populations of adolescents and young adults. For the purpose of this study, rapid-onset gender dysphoria (ROGD) is defined as a type of adolescent-onset or late-onset gender dysphoria where the development of gender dysphoria is observed to begin suddenly during or after puberty in an adolescent or young adult who would not have met criteria for gender dysphoria in childhood. This study was designed to describe rapid-onset gender dysphoria (ROGD) and to generate hypotheses, including the role of social and peer contagion in the development of this condition.

Statistical analyses of quantitative data were performed using Excel and custom shell scripts (Unix). Quantitative findings are presented as frequencies, percentages, ranges, means and/or medians. ANOVAs, chi-squared, and t-tests comparisons were used where appropriate using publicly available calculators and p<0.05 was considered significant. Qualitative data were obtained from open text answers to questions that allowed participants to provide additional information or comments. The types of comments and descriptions were categorized, tallied, and reported numerically. A grounded theory approach was selected as the analytic strategy of choice for handling the qualitative responses because it allowed the researcher to assemble the data in accordance with the salient points the respondents were making without forcing the data into a preconceived theoretical framework of the researcher’s own choosing [ 40 ]. Illustrative respondent quotes and summaries from the qualitative data are used to illustrate the quantitative results and to provide relevant examples. Two questions were targeted for full qualitative analysis of themes (one question on friend group behaviors and one on clinician interactions). For these questions, a second reviewer with expertise in qualitative methods was engaged (MM). Both the author (LL) and reviewer (MM) independently analyzed the content of the open text answers and identified major themes. Discrepancies were resolved with collaborative discussion and themes were explored and refined until agreement was reached for the final lists of themes. Representative quotes for each theme were selected by LL, reviewed by MM, and agreement was reached.

Two questions about the AYAs’ ability to cope with negative and strong emotions were included. One question was “How does your child handle strong emotions? (please select the best answer).” Offered answers were “My child is overwhelmed by strong emotions and goes to great lengths to avoid feeling them,” “My child is overwhelmed by strong emotions and tries to avoid feeling them,” “My child neither avoids not seeks out strong emotions,” “My child tries to seek out situations in order to feel strong emotions,” “My child goes to great lengths to seek out situations in order to feel strong emotions,” “None of the above,” “I don’t know.” The other question was “How would you rate your child’s ability to deal with their negative emotions and channel them into something productive?” An example was given regarding dealing with a low test grade by studying harder for the next test (excellent) or by ignoring it, throwing a tantrum, blaming the teacher or distracting themselves with computer games, alcohol, drugs, etc. (extremely poor). Offered answers were: excellent, good, fair, poor, extremely poor, and I don’t know.

Survey questions were developed to specifically quantify adolescent behaviors that had been described by parents in online discussions and observed elsewhere. Participants were asked to describe outcomes such as their child’s mental well-being and parent-child relationship since becoming transgender-identified. Parents were also asked about experiences with clinicians and their children’s disposition regarding steps taken for transition and duration of transgender-identification both for children who were still transgender-identified and for children who were no longer transgender-identified.

The DSM-5 criteria for gender dysphoria in adolescents and adults ( Fig 3 ) consist of six indicators of gender dysphoria [ 39 ]. To meet criteria for diagnosis, an adolescent or adult must manifest at least two of the six indicators. The six indicators were simplified for language, the first indicator was adjusted for a parent to answer about their child, and parents were asked to note which, if any, their child was expressing currently. The requirement of six-month duration of symptoms was not included.

The DSM 5 criteria for gender dysphoria in children ( Fig 2 ) consist of eight indicators of gender dysphoria [ 39 ]. To meet criteria for diagnosis, a child must manifest at least six out of eight indicators including the one designated A1, “A strong desire to be the other gender or an insistence that one is the other gender (or some alternative gender different from one’s assigned gender).” Three of the indicators (A1, A7, and A8) refer to desires or dislikes of the child and five of the indicators (A2-A6) are readily observable behaviors and preferences. The eight indicators were simplified for language and parents were asked to note which, if any, their child had exhibited prior to puberty. The requirement of six-month duration of symptoms was not included.

Basic demographic and baseline characteristic questions, including parental attitudes about LGBT rights, were included. Parents were asked about their children’s mental health disorders and neurodevelopmental disabilities that were diagnosed before their child’s onset of gender dysphoria as well as during and after. The question, “Has your child been formally identified as academically gifted, learning disabled, both, neither?” was used as a proxy to estimate rates of academic giftedness and learning disabilities. Questions about trauma and non-suicidal self-injury were also included as were questions about social difficulties described in a previous research study about gender dysphoric adolescents [ 19 ].

Participation in this study was voluntary and its purpose was clearly described in the recruitment information. Electronic consent was obtained. Participants had the option to withdraw consent at any time prior to submitting responses. Inclusion criteria were (1) completion of a survey with parental response that the child had a sudden or rapid onset of gender dysphoria; and (2) parental indication that the child’s gender dysphoria began during or after puberty. There was logic embedded in the survey that disqualified surveys that answered “no” (or skipped the question) about whether the child had a sudden or rapid onset of gender dysphoria and 23 surveys were disqualified prior to completion (20 “no” answers and 3 skipped answers). After cleaning the data for the 274 completed surveys, 8 surveys were excluded for not having a sudden or rapid onset of gender dysphoria and 10 surveys were excluded for not having gender dysphoria that began during or after puberty, which left 256 completed surveys for inclusion. As the survey was voluntary there was no refusal or dropout rate.

A 90-question survey instrument with multiple choice, Likert-type, and open-ended questions was created by the researcher. The survey was designed for parents (respondents) to complete about their adolescent and young adult children. The survey was uploaded onto Survey Monkey (SurveyMonkey, Palo Alto, CA, USA) via an account that was HIPPA-enabled. IRB approval for the study from the Icahn School of Medicine at Mount Sinai in New York, NY was received. Recruitment information with a link to the survey was placed on three websites where parents and professionals had been observed to describe rapid onset of gender dysphoria (4thwavenow, transgender trend, and youthtranscriticalprofessionals). Website moderators and potential participants were encouraged to share the recruitment information and link to the survey with any individuals or communities that they thought might include eligible participants to expand the reach of the project through snowball sampling techniques. The survey was active from June 29, 2016 to October 12, 2016 (3.5 months) and took 30–60 minutes to complete. Participants completed the survey at a time and place of their own choosing. Data were collected anonymously and stored securely with Survey Monkey.

During the recruitment period, 256 parents completed online surveys that met the study criteria. The sample of parents included more women (91.7%) than men (8.3%) and participants were predominantly between the ages of 45 and 60 (66.1%) ( Table 1 ). Most respondents were White (91.4%), non-Hispanic (99.2%), and lived in the United States (71.7%). Most respondents had a Bachelor’s degree (37.8%) or graduate degree (33.1%). The adolescents and young adults (AYAs) described by their parents were predominantly female sex at birth (82.8%) with an average current age of 16.4 years (range, 11–27 years). See Table 2 .

Results

Baseline characteristics Baseline characteristics (Table 1) included that the vast majority of parents favored gay and lesbian couples’ right to legally marry (85.9%) and believed that transgender individuals deserve the same rights and protections as other individuals in their country (88.2%). Along with the sudden or rapid onset of gender dysphoria, the AYAs belonged to a friend group where one or multiple friends became gender dysphoric and came out as transgender during a similar time as they did (21.5%), exhibited an increase in their social media/internet use (19.9%), both (45.3%), neither (5.1%), and don’t know (8.2%). For comparisons, the first three categories will be combined and called “social influence” (86.7%) and the last two combined as “no social influence” (13.3%). Nearly half (47.4%) of the AYAs had been formally diagnosed as academically gifted, 4.3% had a learning disability, 10.7% were both gifted and learning disabled, and 37.5% were neither. Sexual orientation as expressed by the AYA prior to transgender-identification is listed separately for natal females and for natal males (Table 2). Overall, 41% of the AYAs expressed a non-heterosexual sexual orientation prior to disclosing a transgender-identification. It is important to note that none of the AYAs described in this study would have met diagnostic criteria for gender dysphoria in childhood (Table 3). In fact, the vast majority (80.4%) had zero indicators from the DSM-5 diagnostic criteria for childhood gender dysphoria with 12.2% possessing one indicator, 3.5% with two indicators, and 2.4% with three indicators. Breaking down these results, for readily observable indicators (A2-6), 83.5% of AYAs had zero indicators, 10.2% had one indicator, 3.9% had two indicators, and 1.2% had three indicators. For the desire/dislike indicators (A1, A7, A8), which a parent would have knowledge of if the child expressed them verbally, but might be unaware if a child did not, 95.7% had zero indicators and 3.5% had one indicator. Parents responded to the question about which, if any, of the indicators of the DSM criteria for adolescent and adult gender dysphoria their child was experiencing currently. The average number of positive current indicators was 3.5 (range 0–6) and 83.2% of the AYA sample was currently experiencing two or more indicators. Thus, while the focal AYAs did not experience childhood gender dysphoria, the majority of those who were the focus of this study were indeed gender dysphoric at the time of the survey completion. PPT PowerPoint slide

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larger image TIFF original image Download: Table 3. DSM 5 Indicators for gender dysphoria. https://doi.org/10.1371/journal.pone.0202330.t003 The AYAs who were the focus of this study had many comorbidities and vulnerabilities predating the onset of their gender dysphoria, including psychiatric disorders, neurodevelopmental disabilites, trauma, non-suicidal self-injury (NSSI), and difficulties coping with strong or negative emotions (Table 4). The majority (62.5%) of AYAs had one or more diagnoses of a psychiatric disorder or neurodevelopmental disability preceding the onset of gender dysphoria (range of the number of pre-existing diagnoses 0–7). Many (48.4%) had experienced a traumatic or stressful event prior to the onset of their gender dysphoria. Open text descriptions of trauma were categorized as “family” (including parental divorce, death of a parent, mental disorder in a sibling or parent), “sex or gender related” (such as rape, attempted rape, sexual harassment, abusive dating relationship, break-up), “social” (such as bullying, social isolation), “moving” (family relocation or change of schools); “psychiatric” (such as psychiatric hospitalization), and medical (such as serious illness or medical hospitalization). Almost half (45.0%) of AYAs were engaging in non-suicidal self-injury (NSSI) behavior before the onset of GD. Coping styles for these AYAs included having a poor or extremely poor ability to handle negative emotions productively (58.0%) and being overwhelmed by strong emotions and trying to avoid (or go to great lengths to avoid) experiencing them (61.4%) (Table 4). The majority of respondents (69.4%) answered that their child had social anxiety during adolescence; 44.3% that their child had difficulty interacting with their peers, and 43.1% that their child had a history of being isolated (not associating with their peers outside of school activities). PPT PowerPoint slide

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larger image TIFF original image Download: Table 4. AYA baseline comorbidities and vulnerabilities predating the onset of gender dysphoria. https://doi.org/10.1371/journal.pone.0202330.t004

Announcing a transgender-identification At the time the AYA announced they were transgender-identified (“came out”), most were living at home with one or both parents (88.3%) and a small number were living at college (6.2%). The average age of announcement of a transgender-identification was 15.2 years of age (range 10–21) (Table 5). Most of the parents (80.9%) answered affirmatively that their child’s announcement of being transgender came “out of the blue without significant prior evidence of gender dysphoria.” Respondents were asked to pinpoint a time when their child seemed not at all gender dysphoric and to estimate the length of time between that point and their child’s announcement of a transgender-identity. Almost a third of respondents (32.4%) noted that their child did not seem gender dysphoric when they made their announcement and 26.0% said the length of time from not seeming gender dysphoric to announcing a transgender identity was between less than a week to three months. The most striking examples of “not seeming at all gender dysphoric” prior to making the announcement included a daughter who loved summers and seemed to love how she looked in a bikini, another daughter who happily wore bikinis and makeup, and another daughter who previously said, “I love my body!” The majority of respondents (69.2%) believed that their child was using language that they found online when they “came out.” A total of 130 participants provided optional open text responses to this question, and responses fell into the following categories: why they thought the child was using language they found online (51); description of what the child said but didn’t provide a reason that they suspected the child was using language they found online (61); something else about the conversation (8) or the child (7) and don’t know (3). Of the 51 responses describing reasons why respondents thought their child was reproducing language they found online, the top two reasons were that it didn’t sound like their child’s voice (19 respondents) and that the parent later looked online and recognized the same words and phrases that their child used when they announced a transgender identity (14 respondents). The observation that it didn’t sound like their child’s voice was also expressed as “sounding scripted,” like their child was “reading from a script,” “wooden,” “like a form letter,” and that it didn’t sound like their child’s words. Parents described finding the words their child said to them “verbatim,” “word for word,” “practically copy and paste,” and “identical” in online and other sources. The following quotes capture these top two observations. One parent said, “It seemed different from the way she usually talked—I remember thinking it was like hearing someone who had memorized a lot of definitions for a vocabulary test.” Another respondent said, “The email [my child sent to me] read like all of the narratives posted online almost word for word.” PPT PowerPoint slide

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larger image TIFF original image Download: Table 5. Announcing a transgender-identification. https://doi.org/10.1371/journal.pone.0202330.t005 The following case summaries were selected to illustrate peer, trauma, and psychiatric contexts that might indicate more complicated clinical pictures. A 12-year-old natal female was bullied specifically for going through early puberty and the responding parent wrote “as a result she said she felt fat and hated her breasts.” She learned online that hating your breasts is a sign of being transgender. She edited her diary (by crossing out existing text and writing in new text) to make it appear that she has always felt that she is transgender.

A 14-year-old natal female and three of her natal female friends were taking group lessons together with a very popular coach. The coach came out as transgender, and, within one year, all four students announced they were also transgender.

A natal female was traumatized by a rape when she was 16 years of age. Before the rape, she was described as a happy girl; after the rape, she became withdrawn and fearful. Several months after the rape, she announced that she was transgender and told her parents that she needed to transition.

A 21-year-old natal male who had been academically successful at a prestigious university seemed depressed for about six months. Since concluding that he was transgender, he went on to have a marked decline in his social functioning and has become increasingly angry and hostile to his family. He refuses to move out or look for a job. His entire family, including several members who are very supportive of the transgender community, believe that he is “suffering from a mental disorder which has nothing to do with gender.”

A 14-year-old natal female and three of her natal female friends are part of a larger friend group that spends much of their time talking about gender and sexuality. The three natal female friends all announced they were trans boys and chose similar masculine names. After spending time with these three friends, the 14-year-old natal female announced that she was also a trans boy. The majority (76.5%) of the surveyed parents felt that their child was incorrect in their belief of being transgender (Table 5). More than a third (33.7%) of the AYAs asked for medical and/or surgical transition at the same time that they announced they were transgender-identified. Two thirds (67.2%) of the AYAs told their parent that they wanted to take cross-sex hormones; 58.7% that they wanted to see a gender therapist/gender clinic; and 53.4% that they wanted surgery for transition. Almost a third (31.2%) of AYAs brought up the issue of suicides in transgender teens as a reason that their parent should agree to treatment. More than half of the AYAs (55.9%) had very high expectations that transitioning would solve their problems in social, academic, occupational or mental health areas. While 43.9% of AYAs were willing to work on basic mental health before seeking gender treatments, a sizable minority (28.1%) were not willing to work on their basic mental health before seeking gender treatment. At least two parents relayed that their child discontinued psychiatric care and medications for pre-existing mental health conditions once they identified as transgender. One parent, in response to the question about if their child had very high expectations that transitioning would solve their problems elaborated, “Very much so. [She] discontinued anti- depressant quickly, stopped seeing psychiatrist, began seeing gender therapist, stopped healthy eating. [She] stated ‘none of it’ (minding what she ate and taking her Rx) ‘mattered anymore.’ This was her cure, in her opinion.”

Friend-group exposure The adolescent and young adult children were, on average, 14.4 years old when their first friend became transgender-identified (Table 6). Within friendship groups, the average number of individuals who became transgender-identified was 3.5 per group. In 36.8% of the friend groups described, the majority of individuals in the group became transgender-identified. The order that the focal AYA “came out” compared to the rest of their friendship group was calculated from the 119 participants who provided the number of friends coming out both before and after their child and 74.8% of the AYAs were first, second or third of their group. Parents described intense group dynamics where friend groups praised and supported people who were transgender-identified and ridiculed and maligned non-transgender people. Where popularity status and activities were known, 60.7% of the AYAs experienced an increased popularity within their friend group when they announced a transgender-identification and 60.0% of the friend groups were known to mock people who were not transgender or LGBTIA (lesbian, gay, bisexual, transgender, intersex, or asexual). PPT PowerPoint slide

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larger image TIFF original image Download: Table 6. Friend group exposure. https://doi.org/10.1371/journal.pone.0202330.t006 For the question about popularity changes when the child came out as having a transgender-identification, 79 participants provided optional open text responses which were categorized as: descriptions of the responses the child received (39); descriptions of the friends (14); description that the child did not “come out” to friends (8); not sure (9); speculation on how the child felt from the response (4), other (5). Of the 39 descriptions of responses, 19 of these responses referred to positive benefits the child received after coming out including positive attention, compliments, increased status, increased popularity, increased numbers of online followers, and improved protection from ongoing bullying. The following are quotes from parents about the perceived benefits of transgender-identification afforded to their child. One respondent said, “Great increase in popularity among the student body at large. Being trans is a gold star in the eyes of other teens.” Another respondent explained, “not so much ‘popularity’ increasing as ‘status’…also she became untouchable in terms of bullying in school as teachers who ignored homophobic bullying …are now all at pains to be hot on the heels of any trans bullying.” Seven respondents described a mixed response where the child’s popularity increased with some friends and decreased with others. Seven respondents described a neutral response such as “All of the friends seemed extremely accepting.” Two described a temporary increase in their child’s popularity: “There was an immediate rush of support when he came out. Those same friends have dwindled to nothing as he rarely speaks to any of them now.” Another described the loss of friends. And two parents described that “coming out” prevented the loss of friends explained by one respondent as “to not be trans one would not have been included in his group.” Several AYAs expressed significant concern about the potential repercussions from their friend group when they concluded that they were not transgender after all. There were two unrelated cases with similar trajectories where the AYAs spent some significant time in a different setting, away from their usual friend group, without access to the internet. Parents described that these AYAs made new friendships, became romantically involved with another person, and during their time away concluded that they were not transgender. In both cases, the adolescents, rather than face their school friends, asked to move and transfer to different high schools. One parent said that their child, “…couldn’t face the stigma of going back to school and being branded as a fake or phony…. Or worse, a traitor or some kind of betrayer…[and] asked us if we could move.” In the other case, the parent relayed that their child thought none of the original friends would understand and expressed a strong desire to “…get out of the culture that ‘if you are cis, then you are bad or oppressive or clueless.’” Both families were able to relocate and both respondents reported that their teens have thrived in their new environments and new schools. One respondent described that their child expressed relief that medical transition was never started and felt there would have been pressure to move forward had the family not moved away from the peer group. Qualitative analysis. The open-ended responses from the question about whether the AYAs and friends mocked, teased, or made fun of individuals who weren’t transgender or LGBTIA was selected for additional qualitative analysis. Seven major themes were identified from the comments provided by participants and are described, with representative supporting quotes. Theme: groups targeted. The groups targeted for mocking by the friend groups are often heterosexual (straight) people and non-transgender people (called “cis” or “cisgender”). Sometimes animosity was also directed towards males, white people, gay and lesbian (non-transgender) people, aromantic and asexual people, and “terfs”. One participant explained, “They are constantly putting down straight, white people for being privileged, dumb and boring.” Another participant elaborated, “In general, cis-gendered people are considered evil and unsupportive, regardless of their actual views on the topic. To be heterosexual, comfortable with the gender you were assigned at birth, and non-minority places you in the ‘most evil’ of categories with this group of friends. Statement of opinions by the evil cis-gendered population are consider phobic and discriminatory and are generally discounted as unenlightened.” Theme: individuals targeted. In addition to targeting specific groups of people for mocking, the AYAs and their friend groups also directed mocking towards individuals in the AYAs’ lives such as parents, grandparents, siblings, peers, allies, and teachers. The following quotes describe individuals targeted. One participant said, “They call kids who are not LGBT dumb and cis. And the mocking has been aimed at my transgender-identified child’s [sibling].” Another parent said, “They definitely made fun of parents and teachers who did not agree with them.” And a third participant said, “…they were asked to leave [a school-based LGBT club] because they were not queer enough [as straight and bisexual allies]. [One of them] was [then] bullied, harassed and denounced online.” Theme: behaviors occurred both in person and in online settings. Parents observed the behaviors both in-person and in online settings, and specifically mentioned seeing posts and conversations on Tumblr, Twitter, Facebook, and Instagram. On participant said, “They speak with derision about how cis-gendered people do not understand them and are so close-minded.” Another participant said, “I hear them disparaging heterosexuality, marriage and nuclear families.” Another participant said, “On my daughter's Tumblr blog, she has liked or favorited or re-posted disparaging comments about those who aren't transgender or seem to misunderstand the transgender identity.” And another parent reported, “Her real life friends don't [mock non-LGBT people] but online they are always swapping jokes and comments about cisgender and about transphobia.” Theme: examples of behaviors. Participants gave many examples of the observed behaviors that were mocking towards non-transgender people and non-LGB people. One participant said, “My daughter called me a ‘breeder’ and says things in a mocking ‘straight person voice’. Her friends egg her on when she does this.” Another parent offered, “If they aren't mocking ‘cis’ people, they are playing pronoun police and mocking people who can't get the pronouns correct.” Another participant said, “New vocabulary includes ‘cis-stupid’ and ‘cis-stupidity.’” And a fourth participant described, “They assume anyone that is critical about being transgender (even just asking questions) is either ignorant or filled with hate.” Theme: emphasizing victimhood. Participants described that their children and friend group seemed to focus on feeling as though they were victims. One participant described, “They seem to wear any problems they may have, real or perceived like badges of honor…I feel like they want to believe they are oppressed & have really 'been through life', when they have little life experience.” Another participant said, “…there is a lot of feeling like a victim [and being] part of a victimized club.” Another parent said “But all talk is very 'victim' centered”. And finally, another said, “They passionately decry ‘Straight Privilege’ and ‘White Male Privilege’—while emphasizing their own ‘Victimhood.’” Theme: consequences of behaviors. A few participants describe that because of their child’s behavior, there were consequences, including making it difficult for one child to return to her school and the following description from another parent, “Most relatives have blocked her on [social media] over constant jokes regarding cis and straight people.” Theme: fueling the behaviors. In some cases, parents describe a synergistic effect of kids encouraging other kids to persist in the behavior as was described in a previous quote, “Her friends egg her on when she does this” as well as the following, “Lots of discussion revolving around how their teachers ‘discriminate’ or are ‘mean’ to them based on their declared LGBTIA identity, and they get each other riled up convincing each other of their persecution by these perceived wrongs … privately they mock our intolerance, and in person act upon these false beliefs by treating us as people out to get them…”

Internet/social media exposure In the time period just before announcing that they were transgender, 63.5% of AYAs exhibited an increase in their internet/social media (Table 7). To assess AYA exposure to existing online content, parents were asked what kind of advice their child received from someone/people online. AYAs had received online advice including how to tell if they were transgender (54.2%); the reasons that they should transition right away (34.7%); that if their parents did not agree for them to take hormones that the parents were “abusive” and “transphobic” (34.3%); that if they waited to transition they would regret it (29.1%); what to say and what not to say to a doctor or therapist in order to convince them to provide hormones (22.3%); that if their parents were reluctant to take them for hormones that they should use the “suicide narrative” (telling the parents that there is a high rate of suicide in transgender teens) to convince them (20.7%); and that it is acceptable to lie or withhold information about one’s medical or psychological history from a doctor or therapist in order to get hormones/get hormones faster (17.5%). Two respondents, in answers to other questions, described that their children later told them what they learned from online discussion lists and sites. One parent reported, “He has told us recently that he was on a bunch of discussion lists and learned tips there. Places where teens and other trans people swap info. Like to use [certain, specific] words [with] the therapist when describing your GD, because [they are] code for potentially suicidal and will get you a diagnosis and Rx for hormones.” Another parent disclosed, “The threat of suicide was huge leverage. What do you say to that? It’s hard to have a steady hand and say no to medical transition when the other option is dead kid. She learned things to say that would push our buttons and get what she wanted and she has told us now that she learned that from trans discussion sites.” PPT PowerPoint slide

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larger image TIFF original image Download: Table 7. Internet/social media exposures. https://doi.org/10.1371/journal.pone.0202330.t007 Parents identified the sources they thought were most influential for their child becoming gender dysphoric. The most frequently answered influences were: YouTube transition videos (63.6%); Tumblr (61.7%); a group of friends they know in person (44.5%); a community/group of people that they met online (42.9%); a person they know in-person (not online) 41.7%. In contrast to the majority of responses, two participants commented that they didn’t think the sources influenced their child to become gender dysphoric, rather they gave their child a name for their feelings or gave the child confidence to come out. The following quotes illustrate the dominant quantitative findings. One parent wrote, “We believe the biggest influence was the online pro-transition blogs and youtube videos. We feel she was highly influenced by the ‘if you are even questioning your gender-you are probably transgender’ philosophy…In the ‘real world’ her friends, other trans peers, and newfound popularity were additional areas of reinforcement.” Another respondent described the online influence as part of a different question, “I believe my child experienced what many kids experience on the cusp of puberty—uncomfortableness!—but there was an online world at the ready to tell her that those very normal feelings meant she's in the wrong body.”

Mental well-being, mental health, and behaviors The trajectories of the AYAs were not consistent with the narrative of discovering one’s authentic self and then thriving. Specifically, parents reported that, after “coming out,” their children exhibited a worsening of their mental well-being. Additionally, parents noted worsening of the parent-child relationship and observed that their children had narrowed their interests (Table 8). Although small numbers of AYAs had improvement in mental well-being (12.6%), parent-child relationship (7.4%), grades/academic performance (6.4%), and had broadened their interests and hobbies (5.1%); the most common outcomes were worsened mental well-being (47.2%); worsened parent child relationship (57.3%); unchanged or mixed grades/academic performance (59.1%); and a narrowed range of interests and hobbies (58.1%). One parent describing her child’s trajectory offered, “After announcing she was transgender, my daughter’s depression increased significantly. She became more withdrawn. She stopped participating in activities which she previously enjoyed, stopped participating in family activities, and significantly decreased her interaction with friends. Her symptoms became so severe that she was placed on medication by her physician.” Table 9 describes cumulative rates of mental illness and neurodevelopmental disability at the time of survey. PPT PowerPoint slide

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larger image TIFF original image Download: Table 8. Outcomes and behaviors. https://doi.org/10.1371/journal.pone.0202330.t008 PPT PowerPoint slide

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larger image TIFF original image Download: Table 9. AYA Cumulative mental disorder and neurodevelopmental disability diagnoses. https://doi.org/10.1371/journal.pone.0202330.t009 A total of 63.8% of the parents have been called “transphobic” or “bigoted” by their children for one or more reasons, the most common being for: disagreeing with the child about the child’s self-assessment of being transgender (51.2%); recommending that the child take more time to figure out if their feelings of gender dysphoria persist or go away (44.6%); expressing concerns for the child’s future if they take hormones and/or have surgery (40.4%); calling their child by the pronouns they used to use (37.9%); telling the child they thought that hormones or surgery would not help them (37.5%); recommending that their child work on other mental health issues first to determine if they are the cause of the dysphoria (33.3%); calling the child by their birth name (33.3%); or recommending a comprehensive mental health evaluation before starting hormones and/or surgery (20.8%) (Table 10). There were eight cases of estrangement. Estrangement was child-initiated in six cases where the child ran away, moved out, or otherwise refused contact with parent. There were two cases where the estrangement was initiated by the parent because the AYA’s outbursts were affecting younger siblings or there was a threat of violence made by the AYA to the parent. PPT PowerPoint slide

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larger image TIFF original image Download: Table 10. Additional behaviors. https://doi.org/10.1371/journal.pone.0202330.t010 AYAs are reported to have exhibited one or more of the following behaviors: expressed distrust of information about gender dysphoria and transgenderism coming from mainstream doctors and psychologists (51.8%); tried to isolate themselves from their family (49.4%); expressed that they only trust information about gender dysphoria and transgenderism that comes from transgender websites and/or transgender people and sources (46.6%); lost interest in activities where participants aren’t predominantly transgender or LGBTIA (32.3%); stopped spending time with friends who were not transgender (25.1%); expressed distrust of people who were not transgender (22.7%) (Table 10). Many AYAs have also: withdrawn from their family (45.0%); told other people or posted on social media that their parent is “transphobic,” “abusive,” or “toxic” because the parent does not agree with child’s self-assessment of being transgender (43.0%); refused to speak to their parent (28.5%), defended the practice of lying to or withholding information from therapists or doctors in order to obtain hormones for transition more quickly (16.5%); tried to run away (6.8%). The behaviors and outcomes listed above were considered significant changes from the child’s baseline behaviors for 71.4% of respondents checking any of the items. There was a subset of eight cases where parents described watching their child have declining mental well-being as they became gender dysphoric and transgender-identified and then had improving mental well-being as they dropped or backed away from a transgender-identification. One parent described a marked change in her daughter when she was out of school temporarily. “[Her] routine was disrupted. She spent all day on the internet, and lost her many school friends—her only friends were on-line and members of the trans community. In three months, my daughter announced she is trans, gender dysphoric, wants binders and top surgery, testosterone shots…she started self-harming. Now back at school…she tweeted that she’s so young, isn’t sure if she is trans, no longer wants to be referred to by the male name she had chosen…Since she has started back at school and is being exposed to a wide variety of people she is WAY happier.” Another parent described, “My daughter’s insight has improved considerably over the last few years, and she has also outgrown the belief that she is transgender. My daughter actually seemed to be looking for a reason for her depression which is now being successfully treated…My daughter is MUCH happier now that she is being treated for her genuine issues. Coming out as trans made her much worse for a while.” There was a subset of 30 cases where the AYAs’ transgender-identification occurred in the context of a decline in their ability to function (such as dropping out of high school or college, needing a leave of absence from high school or college, and/or being unable to obtain or hold a job), which parents reported as a significant change from their child’s baseline behavior. The declines were substantial as 43.3% of these AYAs had been identified as academically gifted students (some described as top of their class in high school, earning outstanding grades at prestigious universities) before they began to fail their classes, drop out of high school or college, and became unable to hold a job. In most of these cases (76.7%), there was one or more psychiatric diagnosis made at the same time or within the year (60.0%) or within two years (16.7%) of the AYA’s new transgender-identification. Of the 23 individuals who had a psychiatric diagnoses made within two years of assuming a transgender-identification, 91.3% (21/23) were diagnosed with depression; 73.9% (17/23) with anxiety; 26.0% (6/23) with bipolar disorder; 17.4% (4/23) with borderline personality disorder; 8.7% (2/23) with psychosis/psychotic episode: and 8.7% (2/23) with an eating disorder.

Clinical encounters Parents were asked if their child had seen a gender therapist, gone to a gender clinic, or seen a physician for the purpose of beginning transition and 92 respondents (36.2%) answered in the affirmative (Table 11). Many of the respondents clarified that their child had seen a clinician regarding their gender dysphoria for evaluation only. Although participants were not asked directly what kind of provider their child saw, specialties that were mentioned in answers included: general psychologists, pediatricians, family doctors, social workers, gender therapists, and endocrinologists. For parents who knew the content of their child’s evaluation, 71.6% reported that the clinician did not explore issues of mental health, previous trauma, or any alternative causes of gender dysphoria before proceeding and 70.0% report that the clinician did not request any medical records before proceeding. Despite all of the AYAs in this study sample having an atypical presentation of gender dysphoria (no gender dysphoria prior to puberty), 23.8% of the parents who knew the content of their child’s visit reported that the child was offered prescriptions for puberty blockers and/or cross-sex hormones at the first visit. PPT PowerPoint slide

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larger image TIFF original image Download: Table 11. Interactions with clinicians. https://doi.org/10.1371/journal.pone.0202330.t011 One participant described, “For the most part, I was extremely frustrated with providers NOT acknowledging the mental disorder, anxiety, depression, etc before recommending hormone replacement therapy.” And two participants described how the clinician treating their child’s gender dysphoria refused to speak with the patients’ primary care physicians. One participant said, “When we phoned the clinic, the doctor was hostile to us, told us to mind our own business. Our family doctor tried to reach our son’s new doctor, but the trans doctor refused to speak with her.” Another respondent shared “The pediatrician/‘gender specialist’ did not return calls or emails from the primary care physician who requested to talk with her about my son’s medical history before she saw and treated him…she disregarded all historical information provided by the family and primary care physician…did not verify any information provided by my…son at his first visit even after being provided with multiple other historical sources which differed significantly from his story.” When asked about whether their child relayed their history completely and accurately to clinicians or whether they misrepresented or omitted parts of their history, of those who knew the content of their child’s visit, 84.2% of the parent respondents were reasonably sure or positive that their child had misrepresented or omitted parts of their history. Twenty-eight participants provided optional open text responses to this question and the responses were categorized into: describing how the parent knew that the child misrepresented their history (5); the content of what the child misrepresented (6 misrepresenting in general, 4 misrepresenting to the clinician for a total of 10 examples); don’t know/not sure (4); expressing certainty (1); and not relevant (8). For the five participants describing how they knew, the reasons included: being present when it happened, reading the report from the gender specialist, being told by their child that the child had misrepresented the truth, and being informed by the child’s psychiatrist. One respondent shared, “I have read the report from the gender specialist and it omits all the relevant context painting an almost unrecognizable picture of my son.” A second parent simply responded, “I was present.” Another respondent relayed about their (natal male) child, “My daughter told me and her mother that the first therapist she saw asked her stereotypical questions…She was afraid that if she didn’t describe herself as a ‘typical girl’ she would not be believed.” And finally, one respondent wrote, “He has said now that he did [misrepresent his history] and used key words he was advised to say.” Ten participants provided 13 examples of the content of misrepresentations and of these, 6 examples could have been easily verified to be false (claiming to be under the care of a psychiatrist, claiming to be on medication to treat a psychiatric condition, how one was doing academically, and claiming a childhood history of having playmates of one sex when the opposite was observed, and claiming strong childhood preferences for specific toys and clothing that is the opposite of what multiple individuals observed). Three of the content examples would have been challenging to verify as false including: how one was feeling as a child, how one was feeling when a picture was taken, and whether one was from an abusive home. And four of the content examples did not provide enough information to determine if they would be easy or challenging to verify as false, such as “My child distorts her history and our family life on a regular basis,” and “He has created an entire narrative that just isn’t true.” In addition to the previously mentioned case where the child literally rewrote her history by editing her diary, there were seven respondents who conveyed a process where their child was constantly rewriting their personal history to make it consistent with the idea that they always were transgender and/or had created a childhood history that was not what others had observed. It is unclear whether this process was deliberate or if the individuals were unaware of their actions. The following are quotes describing this phenomenon. One parent said, “…she is actively rewriting her personal history to support the idea that she was always trans.” Another respondent added,”…my daughter denies events I recollect from her childhood and puberty that contradicts her narrative of ‘always knowing she was a boy.’” Another respondent offered, “He is rewriting his personal history to suit his new narrative.” And a fourth respondent described, “[Our] son has completely made up his childhood to include only girl friends and dressing up in girls clothes and playing with dolls, etc. This is not the same childhood we have seen as parents.” Qualitative analysis. The open-ended comments from the question about whether the clinician explored mental health, trauma or alternative causes of gender dysphoria before proceeding were selected for qualitative analysis. Nine major themes emerged from the data. Each theme is described in the following paragraphs with supporting quotes from participants. Theme: failure to explore mental health, trauma or alternative causes of GD. Parents described that clinicians failed to explore their child’s mental health, trauma, or any alternative causes for the child’s gender dysphoria. This failure to explore mental health and trauma occurred even when patients had a history of mental health disorder or trauma, were currently being treated for a mental health disorder, or were currently experiencing symptoms. One participant said, “Nothing other than gender dysphoria was considered to explain my daughter's desire to transition.” Another participant said, “My daughter saw a child therapist and the therapist was preparing to support transgendering and did not explore the depression and anxiety or previous trauma.” Theme: insufficient evaluation. Another theme was insufficient evaluation where parents described evaluations that were too limited or too superficial to explore mental health, trauma or alternative causes of gender dysphoria. The following are three quotes by three different parents describing insufficient evaluations. One parent said, “The exploration was egregiously insufficient, very shallow, no effort to ask questions, engage in critical thinking about coexisting anxiety, or put on the brakes or even slow down.” Another participant stated, “When we tried to give our son’s trans doctor a medical history of our son, she refused to accept it. She said the half hour diagnosis in her office with him was sufficient, as she considers herself an expert in the field.” And a third parent wrote, “We were STUNNED by the lack of information, medical history sought by therapist and radical treatment suggestion. [One ]visit. The idea is, ‘if they say they were born in the wrong body, they are. To question this will only hurt her and prolong her suffering.’ [Our] daughter has had trauma in [the] past. [She] never was asked about it. [The] therapist did not ask parents a single question about our daughter.” Theme: unwillingness or disinterest in exploring mental health, trauma or alternative causes of GD. Parents described that clinicians did not seem interested or willing to explore alternative causes. One parent described. “Her current therapist seems to accept her self diagnosis of gender dysphoria and follows what she says without seeming too much interested in exploring the sexual trauma in her past.” Another parent wrote, “The Asperger psychiatrist did not seem to care whether our daughter's gender dysphoria stemmed from Asperger's. If our daughter wanted to be male, then that was enough.” And a third parent said. “The therapist did ask about those issues but seemed to want to accept the idea wholeheartedly that my daughter was transgender first and foremost, all other factors aside.” Theme: mental health was explored. A few parents had the experience where the clinician either made an appropriate referral for further evaluation or the issues had been addressed previously. One parent said, “[The] previous mental health issues [were] already explored by other therapists ([my] child was in therapy and medicated before coming out as transgender).” Theme: failure to communicate with patients’ medical providers. Several participants described clinicians who were unwilling to communicate with primary care physicians and mental health professionals even those professionals who were currently treating the patient. One participant relayed, “She did not review the extensive psychiatric records that were available in a shared EMR [electronic medical record] and she did not consult with his outpatient psychiatrist prior to or after starting cross-sex hormonal therapy.” Another parent said, “My child had been seen for mental health issues for several years before presenting this new identity, but the endocrinologist did not consult the mental health professionals for their opinions before offering hormones.” Theme: misrepresentation of information by the patient. Several participants described how their child misrepresented their history to the clinician, thus, limiting the clinician’s ability to adequately explore mental health, trauma and alternative causes. One participant wrote, “At [the] first visit, [my] daughter's dialogue was well-rehearsed, fabricated stories about her life told to get [the] outcome she desired. She parroted people from the internet.” Another parent reported, “My son concealed the trauma and mental health issues that he and the family had experienced.” And a third parent said, “I overheard my son boasting on the phone to his older brother that ‘the doc swallowed everything I said hook, line and sinker. Easiest thing I ever did.’” Theme: transition steps were pushed by the clinician. Some parents described clinicians who seemed to push the process of transition before the patient asked for it. One parent described that the doctor gave her daughter a prescription that she didn’t ask for, “The family doctor who gave her the Androgel Rx [prescription] did NOT ask her many questions (she was surprised by this), nor did he await her assessment by a licensed psychiatrist before giving her this Rx. Nor did she ask him for this Rx.” Another parent reported that she and her child were at the endocrinologist’s office only to ask questions, and described, “…[he] didn't listen to a word we were saying. He was too eager to get us set up with a ‘gender therapist’ to get the legal form he needed to start hormones, all while making sure we set up our next appointment within 6 months to start the hormones…” Theme: parent views were discounted or ignored. Parents describe that the clinicians did not take their concerns seriously. One parent described, “I have to say I don't know, but it is hard to believe that they adequately examined the history of bullying and being ostracized for being different, and the autistic traits that would lend a person like my son to risk everything for identifying with a group. I know that in the few contacts I had with the providers, my concerns were discounted.” And another said, “All of our emails went unanswered and were ignored. We are left out of everything because of our constant questioning of this being right for our daughter [because of her] trauma and current depression, anxiety and self-esteem problems.” Theme: parent had concerns about the clinicians’ competence, professionalism or experience. Parents expressed doubts about the clinicians regarding their experience, competence or professionalism. One parent said, “The clinic told me they explored these issues. I asked the risk manager at [redacted] if they'd considered a personality disorder. ‘Oh, no,’ she laughed. ‘That's only with the older patients, not the teenagers.’ I'm deeply suspicious of their competence.” Another parent described, “What does concern me is that the people she talked to seemed to have no sense of professional duties, but only a mission to promote a specific social ideology.”