A conversation with two of the parents behind ROGD Boys

I talked to Nichole and ML about their work on ROGD Boys, an online resource for parents and clinicians focusing on the new cohort of boys and young men announcing trans identities and seeking transition. Nichole’s son came out as trans as a teenager, following a series of painful upheavals, including the death of a close family member, the breakup of his friend group, and the move to a new school. ML’s son decided to transition at age 20 after experiencing repeated romantic rejections. In both cases, these parents knew that the real story underlying their children’s distress was more complicated and were alarmed by the lack of evidence for transition and felt let down by the lack of resources and support for parents of trans-identified boys and young men. 

What made you decide to launch ROGD Boys?

Nichole: We decided to launch ROGD Boys because we felt that there was important information that needed to be collated into one space and shared with parents as well as professionals who all too often seem to focus only on the girls, treating the boys as a side note. When looking at the research, we found that–among the sudden spike in gender dysphoria diagnoses and young people seeking transition–over 30% are boys. This is a large percentage of those affected, and it seemed that these boys and young men were often overlooked. 

Tell me about a 'typical' ROGD boy.

Nichole: When I started a support group for parents of  ROGD [rapid-onset gender dysphoria] boys four years ago, I had no idea how alike the boys were. In the first six months, 100 parents came to us for support, and I heard the same stories over and over again: highly bright and gifted children, often on the autism spectrum or with ADHD, who had trouble fitting in with their peers. Kids wanting so badly to fit in but unable to find a group that would really accept them. These boys were not “girly,” but they didn’t fit the profile of stereotypical  “jocks,” either. Instead, they were often bright computer nerds who tended to get stuck and ruminate. We also found that these boys often had a girl or group of girls who were pushing them on toward this trans identity. And the other thing that ties these boys together is their pain and self-hatred. Sometimes this self-hatred is rooted in their fears of being a “toxic male,” but they also beat themselves up for just failing to fit in at school and with friends and not being sure where they fit in the world. To a boy in that situation, trans identity and the trans community look like something that might help them find a way out of that pain and self-loathing. 

From your perspective, what are these boys seeking in a trans identity?

Nichole: Relief from pain and self-hatred. They won’t necessarily admit that, though my son did at age 15. He once told me how much pain he had from growing up and expressed the belief that if he transitioned, all of that pain would be gone. 

There are many–often conflicting!–theories about what's going on with this population of boys and young men. What do you think people—researchers, clinicians, activists—tend to get wrong about these boys? What do you wish they knew?

Nichole: There is a lot of misleading and conflicting information about this new population of boys, and our main question should be: why isn’t there more curiosity? We know that–before the rapid influx of patients at gender clinics–these clinics did see young boys and older men. But they rarely saw teen boys and young adult males, so something has changed. Maybe the old boxes–autogynephilia or homosexual-transsexualism–don’t fit anymore. We hear that all these boys are autogynephilic. Some may very well be! But many ROGD boys don’t seem to fit this profile. They may even be terrified of sexuality, which shouldn’t be surprising given the prevalence of autism spectrum disorders and the recognition that young people with autism tend to struggle with sexuality. 

Sometimes it seems like the autogynephilia label is used to shut down curiosity and discussion around boys. But even if every single one of them were autogynephilic, shouldn’t we be curious about why? 

During the summer of 2022, we conducted a survey of more than 100 parents. Based on this survey and our many conversations with parents, it’s clear that this new cohort of boys and young men share some qualities that seem to make them vulnerable to believing that transition is the answer to their problems. Eighty-five percent of these boys are considered by their parents to be gifted, some exceptionally so, with sky-high IQs. This raises an uncomfortable question: why are some of the brightest boys striving to castrate themselves? What’s the relationship between giftedness and trans identification? Anxiety (73%) and depression (56%) were commonly observed before these boys and young men announced their trans identities. More than half of these boys could be described as severely socially isolated. Others suffered serious losses in their families or struggled in the aftermath of their parents’ divorce. Twenty percent of the boys had an autism diagnosis, and an additional 34% showed potential autistic traits, like poor social skills, repetitive behaviors, and inability to maintain eye contact. Parents often saw their sons’ mental health deteriorate after coming out as trans. All of these factors deserve deeper investigation and consideration. 

What are the risks for boys who end up on a medical pathway?

ML: I have a lot to say about the risks of medicalization for boys and young men. The medicalization section of our website goes into the details of the effects of cross-sex hormones–in the case of boys, estrogen–and surgeries like breast implants, penectomies, vaginoplasties, and orchiectomies. 

Let’s start with estrogen. First, let’s consider the purported benefits of cross-sex hormones for males. You would have read a lot about the Chen study published in the New England Journal of Medicine in January 2023, which a recent report that came out of the Yale Law School described as the “longest and largest study to date on gender-affirming medical treatments in youth.”

Whatever you think about the merits of the study (and we have a lot to say about it!) and what they say about the merits of hormones, they themselves had concluded that when it comes to males, other than “appearance congruence” (i.e., how closely a participant's appearance mirrors their idea of what they think “should” look like, which I think is a deeply regressive concept), estrogen had no other effect. (And two people committed suicide within the first 12 months, even when they were being looked after by multi-disciplinary teams at the top four pediatric gender clinics in the country.)* The study looked at four outcome variables other than appearance congruence: depression, anxiety, life satisfaction, and positive affect. Two years of estrogen did not help the boys in any one of these dimensions. And this is the best evidence we have!

Now, the NEJM study does not mention these details upfront, and the researchers don’t emphasize those outcomes in their public appearances. You have to read the paper in detail (the last paragraph on page 244 that spills into the next page)–as well as the supplementary appendix–to understand that. 

This is a common theme in research in this area: the data says one thing, and the results and conclusions say something else! Sometimes it’s just a single line that turns the whole study on its head. For example, the systematic review that was commissioned by WPATH and carried out by researchers at Johns Hopkins on the effects of cross-sex hormones on mental health found low or insufficient levels of evidence on every outcome they looked at – quality of life, depression, anxiety, death by suicide–and on that last outcome, they don’t even find a low level of evidence. They reviewed 20 studies. In almost every study they review, they find serious levels of bias, which renders the evidence very low quality.* They discuss the shortcomings of the studies. However, in the very last line of the document, here’s what they say: “These benefits make hormone therapy an essential component of care that promotes the health and well-being of transgender people.” This sentence comes completely out of nowhere–it almost seems like the sentence was inserted so that it could be copied and pasted everywhere. It’s as if they know that no journalist would read the entire document–they’d just look at the conclusion. 

After coming across several instances of such blatant spin (the Tordoff paper that was published in 2022 is a whole different level of spin altogether), I started wondering: What do we know about any risks from estrogen? Is there any published literature in established medical journals that talks about these risks? It turns out there are plenty of studies, most of them from researchers in Europe.

So, what are these risks? As I mentioned, the fact that there are no psychosocial benefits from estrogen is well-known, even among proponents of gender-affirming care. This is not surprising since, when it comes to the recent research on estrogen in natal males, excess estrogen in the serum in natal males has been shown to be associated with depression–both among adult men and adolescent boys.

There’s quite a bit of evidence that excess estrogen is associated with depression among natal males. Physiologically, recent research shows that estrogen might have many other harmful and life-threatening effects. Twelve months of estrogen treatment among trans-identified males has been shown to be associated with a decrease in serum BDNF levels. That’s significant because a separate study shows that this decrease in serum BDNF level is associated with increased risks of developing major depressive disorder. Lower levels of brain BDNF levels have also been associated with neurodegenerative disorders and found in the brains of patients with Alzheimer's, Parkinson’s, multiple sclerosis, and Huntington’s disease.

There are several studies of trans-identified males that show that high doses of cross-sex hormones lead to subcortical gray matter changes in the brain. A recent rodent study showed that the changes that happen in male rats when estrogen is administered to them are very similar to what happens in the brains of human males.

Specifically, estrogen seemingly reduced the water content in the astrocytes. That disturbs the delicate homeostasis in the brain by increasing the relative concentration of glutamate (the brain's most abundant excitatory neurotransmitter), leading to glutamate excitotoxicity. As the Cleveland Clinic informs us, an increase in glutamate in the brain is associated with higher risks of neurological disorders like Alzheimer's disease, ALS, and other diseases like multiple sclerosis. The rodent research also indicated that this excess estrogen in male rats decreased brain cortical thickness and volume (which other studies have linked to patients with schizophrenia and bipolar disorder and lower levels of general intelligence). Furthermore, it was found to reduce cortical white matter integrity, which is related to cognitive instability.

All of this might have seemed like elaborate theories, but there now is empirical evidence that trans-identified males on long-term estrogen therapy show lower cognitive abilities. This research was presented at the EPATH conference in Ireland last year. Researchers noted this decline among long-term patients at Amsterdam's famed gender clinic, the place where the practice of medicalization of pediatric patients with gender-related distress was first started.

That’s not all. Research in the last few years shows that estrogen therapy among trans-identified males has been associated with higher risks of various autoimmune diseases, from multiple sclerosis (remember the association of MS with an increase in glutamate?) to rheumatoid arthritis and many other auto-immune diseases in between. It’s also been associated with increases in the risks of prostate cancer and breast cancer.

Estrogen dramatically increases the risks of cardiovascular diseases. An interesting aside: the 1,000% increase in risks of cardiovascular disease associated with estrogen use among men is much higher than those associated with rofecoxib (more commonly known as Vioxx), which subsequently led its manufacturer, Merck, to settle with a nearly $5-billion settlement. For people taking rofecoxib, there was “only” a 34% higher chance of coronary heart disease when compared with those taking other non-steroidal anti-inflammatory drugs.

Empirically, we see a much higher incidence of many of these physical and neurological diseases in the transgender population. It is perhaps not a coincidence, therefore, that population cohort studies show that trans-identified males, on average, die decades earlier than their non-trans-identified male peers or women.

What happens after surgeries is even more horrific. Many people know about the Swedish study that compared the deaths of trans-identified males after surgeries in their National Cause of Death Register. They found that 10 years after sex reassignment surgery (SRS), a man has the same risk of dying as a man more than 20 years older who had not undergone this surgery.

What about quality of life? In 2023, researchers published data from Canada’s first vaginoplasty postoperative care clinic, indicating that nearly a quarter of the trans-identified males who were operated on accessed care for surgical complications or pain within the first three years after surgery, with more than half of those seeking care within the first year. More than 60% were seen for more than one visit and presented with two or more symptoms or concerns.

Common patient-reported symptoms during clinical visits included pain (53.8%), dilation concerns (because the body identifies the neovagina as a gaping wound, and so this wound has to be dilated for life, including multiple times daily during the first year) (46.3%), and surgical-site bleeding (42.5%). Sexual function concerns were also common (33.8%), with anorgasmia (inability to orgasm) (11.3%) and dyspareunia (painful intercourse) (11.3%) being the most frequent complications. The most common adverse outcomes identified by healthcare providers included hypergranulation (an excess of granulation tissue that rises above the surface of the wound bed) (38.8%), urinary dysfunction (18.8%), and wound healing issues (12.5%).

There’s no meaningful improvement in their mental health either. The researchers first claimed that there was, but they had to later retract that claim.

This issue – of pushing unproven medical interventions when there is no evidence – is old hat when it comes to medicine in the United States. Several books (here are two: 1, 2) have been written on the subject. It’s even been covered in the popular press.* Less than half of medical care in the United States is based on, or supported by, adequate evidence of their effectiveness. Much of clinical practice in the United States lacks a supporting evidence base, and the research evidence that exists is predominantly of poor quality. So, why should people care? “If doctors do not follow evidence-based guidelines or if medical societies use their power to discredit credible studies demonstrating that a particular treatment is not as effective as advertised, medical professionalism and self-regulation become a myth.”

As a result, we spend much more on healthcare than every rich country and see worse outcomes. Our health and health systems are ranked 69th in the world–lower than 58th-ranked Iran, a country where homosexuality is illegal but where clerics accept the idea that a person may be trapped in the wrong body and have a sex-change procedure with financial assistance from the state “to lead fulfilling lives.”

In the coming years, there will be many people who, back in the day, identified as transgender or non-binary. They will look at our sons and tell their children, “Thank heavens I stopped before making that mistake!” and avert their eyes. Our sons will be a cautionary tale. For our sons, it will be increasingly difficult to admit what happened to them was wrong, especially once the world has moved on. All of us have made our share of mistakes in our youth. That’s one of the rites of passage to adulthood. But then we are afforded the benefit of time to forget our youthful misadventures (and even if we can’t, most of the time, that tragedy is played out in private). That is a luxury that will be denied to our children. Every new disease they get, every latest visit to the emergency, and every recoil from people they encounter on the street will remind them of what they have wrought upon themselves.

Will the doctors and the nurses and the psychologists who are telling our son today that hormones are safe, or the researchers who tell him that these medical interventions are “primarily cosmetic” (yes, that’s what Jack Turban has said – in a published paper) be there for him to hold his hand and pay his bills when he goes to one clinic after another with his various ailments… with his schizophrenia and depression and anxiety and drug dependence and possibly several neurodegenerative diseases? With his blood clots and his autoimmune diseases? Or when he is in an emergency room because of his latest suicide attempt?

Or will it be left to parents, trying to find a way to help their adult man-child whom society has chewed, spat out, and completely forgotten?

What research do you hope to see on this topic in the future?

Nichole: The focus of much ROGD writing and interest is on the girls. Some research has included the boys, such as Lisa Littman’s initial study and some of the research into detransition. However, we need to understand what the internal and external drivers for boys to identify as trans are. We would like to see researchers take up an interest in parent surveys and surveys of the boys themselves. It is important that any research study first consults with parents of boys because if you do not have background information about boys, you will have trouble asking the right questions. For instance, with boys, there is a social aspect, but it doesn’t look like Littman’s observations where there were groups of friends coming out together. Instead, it seems to be driven by a girl or group of girls who are not trans themselves yet encourage the development of a trans identity in their chosen boy, perhaps as a way to signal what good allies they are. It’s important that any future research has some background information about boys in order to make a good assessment.

ML: We would also like to see a greater focus in the medical literature on the harms of estrogen when used as a cross-sex hormone. A recent analysis of Cochrane reviews showed that nearly 37% of medical interventions showed evidence of harm. The study also found that the harms of treatments are measured quite rarely (only a third as much) as compared to the benefits. Medicine – and especially modern American medicine – tries to show us the benefits of a medical intervention but not the harms (with estrogen, it is a whole new level of gaslighting, where even the gender-affirming clinicians cannot show any benefits at all!). The harms are found after many years – sometimes decades even – after the FDA had approved the intervention (and once again, with estrogen, we don’t even have that FDA approval).

When it comes to new research, we already have thousands of papers showing the benefits of the emperor’s new clothes. Every systematic review shows low levels of evidence and high levels of bias in the studies, including the one commissioned by WPATH.* Harms are always difficult to measure – even with OxyContin (manufactured by Purdue Pharma and approved by the FDA), which was at the heart of the opioid crisis and responsible for thousands of deaths every year, it took many years before the extent of the harm became apparent to the general public – and that is for a drug that was prescribed to large swathes of the population. For drugs that are prescribed to smaller segments of the population, it can take much longer before their safety risks are established. We only really get a full picture of the harms years later when individuals manage to get past their inhibitions and speak up about the complications that they suffered. Researchers also will usually find no sponsors for studies that recruit volunteers to record harm from an intervention – can you imagine how difficult it is for a person who regrets their transition to come up and speak about the mistakes they made? The entire complex of gender-affirming care relies on the silence of these people. Then, because there are few vocal detransitioners, advocates point to the “low rates of regret from transition.” We would like to see more research explicitly addressing the issue of harm from these interventions.*

What resources and advice do you have for parents?

Nichole: Parents can find support groups through the website parentsofrogdkids.com and many other resources on our website, rogdboys.org. 

I won't give advice to parents anymore other than to take care of themselves. Sometimes the burden feels too much to bear. 

ML: This work—which concerns the fate of our sons—weighs very heavily on us. There are days when we will meet as a team to discuss changes to the website so that we can communicate to parents (and their children) that it is not necessary to pathologize gender nonconformity or the discomfort of simply growing up, only to come across an essay in the New York Times spouting some nonsense about a “transcendent sense of gender” that “goes beyond language.” There are nights when we will wake up to find our spouse doom-scrolling, when both of us know that the other is awake but pretend that we don’t because we don’t know what to say. Often it feels like we cannot save our children with all the advice in the world, and all it does is make parents more upset because nothing is working. So, parents, please, first take care of yourselves. Yes, we know that you were told that they would feel euphoric after transitioning. We were told the same. And yet, all we see are our boys, who are even more stuck in their rooms and even more miserable than ever. However, we cannot help them if we haven’t rested ourselves or are going through inordinate amounts of stress in our daily lives.

What do you hope to offer [via ROGD Boys] in the future?

ML: All of us involved with ROGD Boys come from a scientific background. When we meet, we leave our political affiliations at the door. We want ROGD Boys to be a resource for parents and the boys based on what the science tells us. Other people might have time for identities and politics, but we do not. All that matters to us are our suffering children. And we will move heaven and earth to alleviate that suffering. We know—from hard-earned experience—that outsourcing their distress to magical thinking by people who don’t know our children and don’t know the science isn’t going to help. And so, we hope that our website becomes a resource for parents who are getting into this madness for the first time in their lives so that they know that they aren’t alone. That there are thousands of parents with boys who are brainy and quirky and uncomfortable about their place in a world that seems to emphasize performativity over substance. Who come out as transgender using the exact same script as thousands of other boys. And, far from being autogynephilic, in many cases, they are scared of their sexuality.

When the website went live, we were inundated by messages from parents saying that they wish this website existed two, three, or five years before, when their happy teenage son suddenly came out as transgender (for many, this coincided with the pandemic). We will continue to be a resource for them so that, when faced by some doctor, lawyer, politician, or just a well-wisher who wants to “help,” they can calmly present the evidence—the evidence as it actually exists, not the evidence spun into something that it does not, in fact, show. At the very least, we hope that the website helps reassure them that they’re not going mad when they think that the entire edifice does not make sense. 

Apologies! There’s not a great way to do footnotes:

1. That rate of suicide is more than 24 times higher than what was observed among children in the NHS GIDS clinic, either receiving hormones or on the waiting list. The latest data from NHS England shows a total of 12 suicides in six years among all children in England who were referred to the NHS.

2. To understand why a few good studies trumps a large quantity of low-quality studies, consider the evidence behind UFO sightings. In the US, the government receives hundreds to thousands of UFO sighting reports per year. Most people agree that these relatively huge numbers of sightings might make for clickbait headlines, but do not imply proof of existence.

3. In 2015, Dr. Atul Gawande wrote an article called “Overkill” in the New Yorker: “Millions of people are receiving drugs that aren’t helping them, operations that aren’t going to make them better, and scans and tests that do nothing beneficial for them, and often cause harm.” But even he couldn’t have imagined what was about to happen in less than ten years.

4. The WPATH-commissioned review, after discussing all the limitations of the studies in six large paragraphs, then suddenly slipped in the line, “Despite the limitations of the available evidence, however, our review indicates that gender-affirming hormone therapy is likely associated with improvements in QOL, depression, and anxiety,” a sentiment that is completely unsupported in the rest of the document. 

5. Placebo effects are routinely very strong in psychiatric medicine, in just a few weeks. Even in double-blind clinical trials of treatments for pain or psychiatric disorders, the responses to placebo are often similar to the responses to active treatment. So, when the NEJM studies show effect sizes of 0.2 or 0.25 or thereabouts among the girls – statistically significant but clinically meaningless changes – after two years, the question arises: is it possible that these interventions are actually harmful?