To J.K. Rowling: A reply to your letter on transgender issues.

(A very brief message to anyone who doesn’t know the background: The letter to which I’m replying is here, and was posted by JKR after numerous concerns about her views on transgender issues. The backstory about the concerns is… pretty much everywhere on the internet, so if you haven’t already seen it just search.)

 

Dear J.K. Rowling,

OK, this feels… seriously strange. I’m writing this to you but also to others reading or following the current discussion (I do plan to post this publicly on my blog) so it seems strange addressing it to you when I know that, realistically, out of all the people who might read it, you’re one person who almost certainly won’t. But I’m doing so because thinking of this as something you could potentially read keeps me focused on the fact that what I write here isn’t just addressing a collection of views and statements I disagree with, but a human being with real feelings about this.

So. I’m writing this because, having followed the story so far about things you’ve said on transgender-related subjects, I’ve now read the letter you posted on your website. And, whatever else I’ve thought about your views on this topic and how you’ve expressed them, I think that letter was an incredibly brave attempt to open up about something that’s really hard for you and about which you have genuine concerns, and I also know you speak for a lot of people who feel the same way.

And I also disagree with almost every point you made.

So what I want to do… well, I struggled to put this into words, but then realised you’d already done it for me. You wrote:

All I’m asking – all I want – is for similar empathy, similar understanding, to be extended to the many millions of women whose sole crime is wanting their concerns to be heard without receiving threats and abuse.

That’s it. That nails it. I want to be able to hear your concerns and extend sympathy and understanding and also extend that same empathy and understanding to the many, many trans people out there who also desperately need their concerns to be heard and understood without being met with threats or abuse. I want to keep that sympathy and understanding for all concerned at the forefront of my mind as I talk about the points you raised and explain why I disagree. And I hope that, even though you yourself will almost certainly never see this letter, at least some of the people who feel the same way as you will be willing to read what I write in that same spirit and to try for a greater overall understanding.

There’s so much in your letter I want to talk about, and it’s going to take me more than one post to do so. But in this post I’m going to skip straight to your last point, because it’s the nub of the whole thing. What you’ve voiced, here, is a fear that a lot of people hold. And I think that fact gets obscured sometimes by the way these same concerns are so often used as excuses by bigots to justify anti-trans agendas held for much darker reasons; in the midst of the damage those people cause, it’s easy to forget that many people quite genuinely are scared of the scenario you’ve just voiced here:

At the same time, I do not want to make natal girls and women less safe. When you throw open the doors of bathrooms and changing rooms to any man who believes or feels he’s a woman – and, as I’ve said, gender confirmation certificates may now be granted without any need for surgery or hormones – then you open the door to any and all men who wish to come inside. That is the simple truth.

Firstly, before doing anything else, I want to correct one point, which is your claim that ‘gender confirmation certificates may now be granted without any need for surgery or hormones’. I think this might be technically correct, in that the current law in the UK doesn’t specify that a transgender person needs to have done anything physically about transitioning before applying for a GRC. It does, however, specify that a person can only apply if (among other restrictions) they have lived as the gender in question for two years and are over 18, and that sounds as though it would in practice be virtually impossible to do without physically transitioning. Also, from what I’ve read, getting a GRC is incredibly difficult under the current system; it certainly doesn’t sound as though, in practice, one would be issued to anyone who hadn’t already transitioned.

People are certainly campaigning to have GRCs issued much more easily (with good reason, from what I’ve read in the previous link), but, as far as I’ve been able to find out, the law hasn’t yet been changed. So, the law you have concerns about is actually a proposed law rather than one that’s currently in place. I know that doesn’t in itself affect your concerns, but thought it important to get the facts straight before starting to discuss them.

Anyway. The fear I assume you’re alluding to here – the one shared by many other people who have concerns about trans rights – is that making it easier to gain a gender recognition certificate will lead to male abusers fraudulently gaining gender confirmation certificates naming them to be female in order to enter bathrooms or changing rooms to… oh, well, you know the rest. And I get that that’s a prospect that many people find really concerning (especially, as you said, people with a history of abuse who can find it quite viscerally terrifying).

Here is what does not make sense and has never made sense to me about this scenario, though. Please tell me if you think I’m missing something, but…

Nobody has to show proof of gender to get into public toilets or changing rooms anyway.

(Warning: this discussion has the potential to be triggering to people who fear the thought of male abusers getting into women’s spaces.)

There is no-one standing outside women’s toilets making sure only people who are legally female get in. There usually is someone standing outside changing rooms, but that’s only to make sure people don’t steal the stock; I’ve never heard of anyone checking documentation on the people who go in. So, how does having or not having a gender recognition certificate make any practical difference to these things at all?

As far as I can find, it isn’t even illegal for men to enter women’s toilets. I mean, stop me if I’m wrong about that; I’m not a lawyer, I’m someone who spent five minutes doing an internet search. But I can’t see how it could, in practice, be made illegal for men to enter women’s toilets without causing masses of problems. There are cleaners who are male, there are severely disabled people who need help in toilets and have carers of the opposite gender, there are times when one set of toilets is out of order and the only option is to let people into the other set, there are people with medical conditions that mean they sometimes need a toilet so urgently they can’t take even a few seconds to run round a building looking for the one they’re supposed to be in. There are also thousands of transgender people who don’t have a gender confirmation certificate and thus, even if they’ve transitioned, are still legally recorded as whatever gender was assigned to them at birth. A blanket law stating that men can’t go into women’s toilets would affect people from all those groups… without actually doing much about the very group that we’re worried about here, since a sexual abuser is pretty much by definition not put off by the prospect of breaking the law.

Why is there all this worry that an abuser might go to the work of filling out a form and paying a fee (currently £140) to get access to a public toilet, when he can just walk straight in anyway?

I get that, for the people who are scared about this, that probably doesn’t help much. I get that fears aren’t logical and don’t just vanish as a result of being told that the thing in question isn’t actually harmful. I get that trying to put legal barriers in the way of people with male anatomy or male chromosomes getting into female spaces makes some women feel safer even if it isn’t doing one darned thing in practice to make them safer. I get that fears of things that don’t in practice actually increase your danger level are still fears and still horrible and still real and important emotions. I feel deep sympathy for any woman or girl who’s frightened by the thought of a person with a penis possibly being in a public toilet next to the one she’s in. I hope that anyone who does feel that way has help and support to deal with her fears, and if you have any ideas that might help you or other people affected by this fear feel safer without harming or risking another group of people, I would love to hear about them and see them implemented.

But ‘keep gender confirmation certificates difficult to obtain’ isn’t such an answer. The reason people are campaigning to make GRCs easier to obtain is because the current process is horrendous. (See also this article which I linked to above.) So, when you advocate keeping GRCs difficult to obtain, you are in fact supporting a system that causes massive problems for transgender people without having any actual benefit.

It’s even worse than that, though. In the USA, this myth about trans rights increasing the risk of sexual abuse is one that is being deliberately and actively weaponised by powerful hate groups with anti-trans ideologies. Warning here for descriptions of very serious assaults at some of the following links… because this climate of whipped-up fears drastically increases the risk of assault on trans people generally, and it also increases the risk of public bathroom use for any woman who can potentially be mistaken for a man, whether this is because she actually is trans, because she’s gender non-conforming, or because she just happens to look androgynous. Trans people have to live in fear of something as simple and everyday as using public bathrooms, because for them it is actually dangerous to do so.

I don’t think the UK is as bad from that point of view – we don’t have the Religious Right to the same degree as they have on that side of the Atlantic – but trans people here still suffer transphobia and anti-trans bigotry and even violent assaults, and the fears you’ve described here are a big part of what drives this. I believe you completely when you say that this is not what you want, that you want everyone including trans people to be safe and protected and free from harm. But good intentions don’t mitigate the effects of supporting harmful policies; the policy you’ve just supported above (not to mention the transphobic activists whose pages you read) are, in practice, contributing to the climate that causes these assaults.

So, when I disagree with you, when I stand up against the beliefs you’re supporting, it is not because I dismiss your fears. It is not because I don’t sympathise or want to help. It is because your fears and my sympathy should not be used to support actions that, while doing nothing to change the risk of the abuse you fear, will increase the abuse risk for transgender people and the level of other problems they face. It’s not OK for them to be the collateral damage of your attempts to ease your fears.

J. K. Rowling, if you do ever read this, thank you for all the joy your books have given to me and to my daughter over the years.

Be well,

Sarah

 

(I will hereby stress once again that all comments – from whichever side of the issue – should be polite and respectful. Yes, this means you. Think of how you would wish someone to talk about an issue that’s extremely sensitive to you, and use that same level of respect. Thank you.)

A reply to Lenny Esposito of Come Reason

Lenny Esposito, author of the Christian apologetics site Come Reason, regularly posts ‘in case you missed it’ tweets with links to his past posts; a recent one was to a post from three years ago titled Progressives, Please Help Me Understand International Women’s Day. Since I seem to fit the definition of ‘progressive’, I’ll give it a shot, for what my opinion is worth. As always, please keep comments polite and respectful.

These are the four main questions in the post:

1. How Do We Mark Achievements Today?

You can find examples on the International Women’s Day site under the top menu ‘Missions’.

2. How Do We Accelerate Economic Gender Parity?/3. How Do We Accelerate Cultural Gender Parity?

Huge and important questions; I’ve aimed to give a quick overview rather than an exclusive list. Feel free to chime in with suggestions in the comments.

This article and this article have general suggestions.

This article, this article, and this article have advice on promoting gender parity in the workplace.

This article has advice on promoting gender parity in the home/the family.

Some other thoughts from me: Take relationship abuse and sexual abuse/harassment seriously, and be aware of the many ways in which they can look different from the stereotypes. Make birth control freely and easily accessible to everyone who needs it. And be willing to listen to people’s stories of their lived experience and take them seriously.

4. What do You Mean by Woman?

Short(ish) answer: Any adult whose gender identity is female. For purposes of anti-misogyny endeavours such as International Women’s Day, I would also include a) girls (children whose gender identity is female), and b) anyone who is affected by misogyny as a result of having been determined on the basis of genital configuration to be female, even if their actual gender identity isn’t female. There was going to be a long answer, but it was getting really long and taking forever to write and in the end I decided I just wanted to get this post published already, so I’ve cut that bit and saved it so that if I have more time later I can put it in a future post.

 

As well as those main questions, the post also contained several subsidiary questions, so here are answers to some of those:

[regarding the ‘A Day Without A Woman‘ strike] How does this celebrate achievement?

The strike wasn’t for celebrating achievement, but for protesting the ways in which women (or trans men who still present as women, as per question 4 above) are still disadvantaged or oppressed in society, and for highlighting the extent of invisible work done in society by women or by trans people thought to be female.

[regarding schools with all-female staff on the ‘A Day Without A Woman’ strike] What happens to the female students who are supposed to be taught today?

Same as what happens to the male or transgender students in those schools; they miss one day’s worth of school and catch up over the rest of the year.

Does losing one day’s instruction give them an advantage?

If you’re honest about wanting to understand these issues better, skip the sarcasm; it’s counter-productive.

In educational terms, of course it doesn’t give these children an advantage, but I can’t imagine it’s going to give them a disadvantage compared to other schools; if having your school very occasionally closed for a day puts you at an educational disadvantage, then surely students from the parts of a country with higher snowfall would do worse educationally than students from the warmer areas due to having more snow days during their childhood. In terms of issues other than education, I think it can be an advantage; they see their teachers willing to get involved in protests for what they believe, and I think that’s a positive thing for children to see.

Perhaps we can recognize that women as women offer unique and worthwhile contributions to our society that cannot be measured (or are undervalued) economically. But this seems to get sticky pretty fast.

It can, but not for the reason you’re giving. The trouble with talking about ‘unique contributions of women’ is that it’s an approach which lumps women together as some sort of composite group who supposedly can collectively make contributions men can’t, with the inevitable vice-versa. The trouble with that is that it pigeonholes people. So, for example, a focus on the idea that women have unique gifts for childcare and home-making is frequently used to give women the message that they have to have children/be the primary carer for those children/eschew other careers, while at the same time giving men the message that they don’t get to be stay-at-home carers for their children because that’s a ‘women’s job’. And that sort of pigeonholing limits everyone and harms a lot of people. So I’d rather focus on the fact that each individual can offer unique contributions, and that gender – however you measure it – isn’t the best way to determine what those contributions are going to be.

Progressives have been telling me for a long time that children don’t need women as mothers, they simply need loving individuals. Gender doesn’t matter at all.

The second sentence there might have been meant to echo the first sentence, but it’s actually saying something rather different. There is a difference between ‘don’t need’ and ‘doesn’t matter at all’. I don’t think that gender ‘doesn’t matter at all’, and, in this specific context, I don’t think it makes zero difference to a child’s experience of being parented. But what children need is loving parents who can provide them with a secure and stable home. Your next comment is about how this relates to adoption, and, yes, I believe that adults who can provide this should be allowed to raise children even if their home doesn’t contain two parents of conventionally opposite genders; I’d far, far rather see children in a happy secure home with a parent or parents who love them than stuck in foster care limbo waiting for some mythical perfect home that doesn’t exist.

All that is required to be a woman is to identify as a woman. Is that right? But that means I can be celebrated if I choose to identify as a woman today.

Transgenderism (and cisgenderism, for that matter) isn’t about ‘choosing’ to identify as a particular gender. It’s about the inescapable fact that nearly all of us do identify as particular genders – not because we choose to, but because it’s a key part of us – and that sometimes a person’s gender identity doesn’t match the gender of their body.

Your choice of words here makes me fairly sure that you don’t actually identify as a woman. I mean, if I’m wrong about that and you are secretly a trans woman in the closet, then, yes, I would absolutely consider it worth celebrating if you felt able to come out. If not, then, no, you shouldn’t just be choosing to say you identify as a woman if you actually don’t.

The big question in all this is how do we celebrate the achievements of women and rally to gain parity for women when the concept of what a woman is isn’t defined? This is probably where I need the most help, as I can’t make sense of it at all.

Of the suggestions above about ways to work for gender parity, which do you feel you can’t implement due to the existence of transgenderism? Why?

I mean, there are those who deeply identify as football fans or basketball fans. I’m in the minority as a hockey fan. Should I seek a day for celebration of achievement and a call to parity since hockey fans are so underrepresented in society?

Lenny… celebrate what you want to celebrate, but cut out the attempts at point-scoring. I don’t think that being a hockey fan has a negative impact on your pay scale, or your risk of experiencing sexual assault or domestic violence, or on any major aspects of your life. I don’t know whether you meant any of your other questions more seriously than this one, but, because I prefer to assume the best of people where possible, I’ve taken them as meant in good faith and answered them in that spirit. If you’re being honest about wanting to learn and understand, then I hope it helped with that. But, whether the rest of the post was meant honestly or not, please don’t post trivialising comparisons for issues that so many people don’t have the luxury of dismissing as trivial.

Yesterday was International Transgender Day of Visibility

Since I didn’t have time to write something myself, here’s a round-up of posts on the subject from FTB-ers:

In Happy International Day of Trans Visibility! Abe Drayton from Oceanoxia has put together a collection of links on the subject.

In With Head Held High, Rhiannon from Intransitive points out the importance of greater visibility for marginalised groups, so that members of those groups aren’t left self-blaming and alone. From this post, I also found the Tumblr Assigned Male, which uses some rather nice cartoons to explain transgender issues.

In I made a video for the Trans Day of Visibility, PZ Myers at Pharyngula posts… well, a video he made, obviously. It’s called ‘The Fallacy of Biological Sex’, and seems to mention something about myths about athletes, which looks interesting.

In The Invisible Queer, Great American Satan at the blog of the same name muses a little on being genderqueer.

Best wishes for rights and societal acceptance to people everywhere, and may transgender people everywhere get to enjoy the comforts that so many cisgender people take for granted.

The Transphobic Comments Of Dr Jacob Edward Les

Siobhan, a blogger on this site, has posted an article on one Dr Les of Calgary, titled Calgary Physician Calls Transgender People “Demented, Distorted”. She quotes, with links, multiple examples of frighteningly transphobic comments Dr Les has made on his blog or Twitter account.

In the post at the first link Shiv gives, for example, Dr Les dismisses gender identity as a belief that’s ‘soft-headed’, ‘blithering idiocy’, and ‘dangerous bunk’. He also describes the AAP guidelines on care for transgender youth as recommending that transgender children be ‘ushered post-haste down the injurious road to sex reassignment’, which is, quite frankly, a bare-faced lie. (And a very dangerous lie for transgender children whose parents make the mistake of trusting Dr Les to be honest with them on this point and don’t check the guidelines out for themselves to see that this doesn’t remotely represent the advice they give. This dishonest scaremongering could put people off seeking the help their children need.)

This is really bad behaviour from someone who, as a doctor, has a responsibility to show the public a better side. It’s horrifying that he feels it appropriate not only to hold these kinds of bigoted, simplistic beliefs without finding out more, but also to express them in such insulting terms.

You can read more in Shiv’s article; she’s read more of his work than I’d be able to stomach.

Gender dysphoria in children – replacing myth with fact. Part Two.

Quick background: This is a follow-on from the post I wrote in response to SkepDoc Harriet Hall’s sadly misleading post Gender Dysphoria in Children. In my reply, I challenged the myth that children with gender dysphoria are being pushed or rushed into transitioning at very young ages. In fact, international medical guidelines on the subject are clear that medical treatment for children with gender dysphoria should not be started prior to puberty (for more on recommended management of younger children with gender dysphoria, see Part One).

I’m writing Part Two because I realised there is a fairly obvious follow-up question that readers might have; while that’s all well and good, why are children starting medical treatment for gender dysphoria during puberty? After all, at this stage they’re still children. Surely, runs this line of argument, it would be better for them to wait until adulthood before any decision is made about medical therapy with its possible (or definite) long-term consequences? It’s an argument that sounds superficially logical and has convinced many people.

Unfortunately, there is a huge problem with it: Children’s bodies are not going to wait. When the decision arises as to whether a pubertal child with gender dysphoria should start medical treatment or not, the alternative to treatment is not going to be that everything remains comfortably in status quo for several more years while the child grows up. The alternative is going to be that the child goes through the significant biological changes that come with puberty.

For a child with persistent gender dysphoria, this is a very big problem. If you read Part One of this, you might remember the Steensma et al research study that looked at the differences between ‘desisters’ and ‘persisters’ with gender dysphoria, and found that the onset of pubertal changes had been a key point for the children they surveyed; while those changes improved the desisters’ feelings of gender dysphoria, they worsened the gender dysphoria symptoms for the persisters. A lot. Children who already felt uncomfortable and out of place with having a body whose gender didn’t match theirs were faced with that body developing much more specific features of that gender… and they found this quite a horrific sensation.

It was terrible, I constantly wanted to know whether I was already in puberty or not. I knew about the puberty blocking treatment and I wanted to be in time. I really did not want to have breasts, I felt like, if they would grow, I would remove them myself. I absolutely did not want them!

I noticed the Adam’s apple of my brother, and an uneasy feeling stole upon me. If I would get an Adam’s apple like his, I did not want to live.

When I was 13, I started to menstruate and my breasts started to grow. I hated it! If we would have had a train station in our town I would definitely have jumped in front of a train. I didn’t go to school anymore, lost my friends and became totally withdrawn.

As soon as puberty started, I could no longer be myself. A boy does not have breasts. As a child it didn’t matter that much, boys and girls don’t differ except that boys have a penis, and girls don’t. But the way I was changing was very wrong. I couldn’t hide it anymore.

At the time my breasts started to grow, I wanted to hide them. I always tried to wear loose shirts. I felt so insecure that I didn’t want other people to see me. So I frequently skipped school and they suspended me. Then I became even more withdrawn.

Before puberty started, I felt physically a boy, but when my breasts started growing, I felt more like a mutant.

(quotes from young people with persistent gender dysphoria in Steensma et al., ‘Desisting and persisting gender dysphoria after childhood: A qualitative follow-up study‘, Clin Child Psychol Psychiatry 2011; 16(4): 499 – 516)

(With regard to the suicidal impulses expressed by some of these patients; yes, this is a very real risk. Several studies have shown a very high rate of suicide attempts among transgender people, and many of these work. Transitioning, and general acceptance and support from others, have both been shown to decrease this risk significantly.)

Imagine, for a minute, that you read or hear a story about doctors at a gender identity clinic forcing a child to go through puberty in the gender that isn’t theirs, against that child’s wishes, even though the child was distressed about it to the point of suicidal unhappiness. We’d all be appalled at the thought. Well… that’s what children with gender dysphoria of this severity go through when made to experience puberty without medical treatment. Their body doesn’t match their gender identity; when they  go through puberty, they’re having to deal with their body becoming more and more obviously that of a gender that isn’t theirs.

As though that wasn’t bad enough, forcing children to endure the wrong puberty has long-term consequences as well; that child is now going forward into adulthood with physical changes that are much harder to reverse. If that child is a transgender girl (a child with the physical body of a boy, but with the internal gender identity of a girl), then she’s had to develop facial hair, stronger facial features, and a deep masculine-sounding voice. She’s going to be stuck with the choice between either having a lot of difficult (and expensive) procedures to reverse these, or spending her life looking and sounding noticeably male even once she starts taking hormone treatment to transition (with all the considerable social stigma and unpleasantness that this will cause her). If that child is a transgender boy who wants to transition physically, his eventual transition will have to include surgery to remove the breasts that could have been prevented from growing in the first place.

There are times in life when doing nothing is a decision. It might be a default decision rather than an active one, but it’s still a decision and it still has consequences. When a persistently transgender child has started puberty, is becoming frantic with the changes, is becoming ever more certain about their decision to transition, is faced with puberty still proceeding apace… then that’s one of those times. In such a situation, doing nothing – withholding medical treatment, insisting that the child has to endure all these changes for years more before being allowed to start treatment for them – is outright harmful to that child.

Of course, it’s also preferable for children not to be making a final decision about transition at that point. After all, we’re talking here about children who are in the early stages of puberty, hence in their early teens at most and in many cases younger than that. Whatever myths you might have heard about gender identity clinics, the professionals there are in fact fully aware that children might change their mind, and are not in any sort of hurry to rush a young child into anything irreversible or even difficult to reverse. So, when a child with persistent gender dysphoria is finding that the early changes of puberty are making the symptoms worse and not better, this presents a dilemma.

Here, therefore, is the management that the WPATH (the international) guidelines advise in such a situation:

When, and only when, a child has persistent and intense symptoms of gender identity issues that are getting worse rather than better with puberty, and other issues in the child’s life have been looked for and dealt with so that this isn’t a case of, say, a child making a poor decision due to severe depression or anxiety, and the child wishes to start treatment after a full discussion of the pros and cons with child and family… then doctors will start a type of treatment known as a puberty blocker. This does not cause any physical gender changes; as the name suggests, it blocks the hormones that cause pubertal changes, thus allowing doctors to hit the ‘pause’ button on the child’s puberty and give them a few extra years to make a decision about gender transition. During this time, the child should be under the care of a paediatric endocrinologist who monitors their response to the puberty blocker and is on the lookout for any side-effects.

If the child’s gender dysphoria persists, and remains at such a level that they wish to physically transition, the next step is hormonal transitioning; taking either testosterone or oestrogen, as the case might be, to bring about the bodily changes of the gender with which the child identifies. (At this point, most people do go on to transition – after all, by this stage you’re down to a subset of transgender children with severe and persistent problems – but it isn’t inevitable. Children who decide against transitioning can simply stop the puberty blockers and allow puberty to proceed normally.) While this is, of course, the point at which changes do start becoming irreversible, that still doesn’t happen straight away. This isn’t like waking up from surgery; the hormonally-induced body changes need to be there for some weeks before they gradually become irreversible, whereas if someone finds that the changes towards a different body are distressing then that reaction is going to be present from an early stage. So, even at this point, we’re still talking about having some leeway to stop things; you haven’t committed irreversibly to gender transition from the moment you swallow your first pill.

The decision about whether or not to transition hormonally is generally taken and implemented around the age of 16, though that’s not an absolute. Again, this is a compromise; the desirability of giving children as much time as feasible to make this decision has to be weighed against the distress of being in a wrong-gender body plus the psychosocial and sometimes physical ramifications of postponing puberty.

As for genital surgery, the guidelines advise that this should be postponed until adulthood. (They also advise waiting until the person has lived as the gender in question for at least twelve months.) It is worth noting here, by the way, that surgery is by no means an inevitable step of transitioning; it’s the one step that everyone who doesn’t know much about transgender treatment will focus on, but in fact many transgender people find that transitioning with the use of hormones is enough for them and that, once the rest of their body matches their inner gender identity, they can deal with having a wrong-gender set of genitals. Either way, it is recommended that this step not be taken prior to adulthood.

Now, hopefully it should be clear by now that the reason for this protocol is that so far it’s the best compromise that exists between the potential risks of treatment and the known risks of not treating an adolescent with severe gender dysphoria who is distressed by pubertal changes. Whatever myths you might have heard, no-one is recommending this because they are oblivious to the potential side-effects of medication or because they think that prescribing for a child is an ideal and sought-after situation. It isn’t. The ideal situation would be for everyone to be born into a body that matches their own inner gender, so that transgender problems wouldn’t exist. For that matter, the ideal situation would be for no child ever to have a condition serious enough to need medication; I don’t know of anyone who wouldn’t be delighted with that situation.

But that, of course, isn’t the situation we’ve got. We have the real world. Some children have serious, or potentially serious, medical conditions which do require treatment; not because medicating children is ideal, but because the consequences of not prescribing for a child with a serious problem can be worse. One such problem is severe gender dysphoria. We can leave children in such a situation to suffer the consequences of an untreated condition – knowing there is a high risk that those consequences will have a serious and significant impact on the child – or we can offer them treatment. It’s hard to believe that any of us would choose the former option were it any other medical condition involved. Why should we do so for children with gender dysphoria?

Gender dysphoria in children – replacing myth with fact, Part One

There is a widespread and pervasive myth that children are frequently being pushed into gender transition therapies. It’s a dangerous myth, because the pushback against it is contributing significantly to the problems that transgender youth have in actually getting appropriate, evidence-based support and therapy. Unfortunately, doctor and blogger Harriet Hall’s recent post Gender Dysphoria in Children appears to have been heavily influenced by this myth, with clumsily researched and pervasively scaremongering results.

There are a lot of highly misleading statements in the post that I’d like to debunk if possible. I’m realistic about my rate of blogging, however; if I get time to reply to other statements in her post then I will, but, for this post, I’m going to concentrate on the central myth here.

(Hat tip to FTB blogger Hj Hornbeck, who mentioned Hall’s post to FTB. His own reply to it is here, so do check that out as well, for a lot more information on the subject.)

I’m going to reply, here, to one particular quote from early in Hall’s post which is not in fact from Hall herself; it was a comment she found on this post. I chose this particular paragraph to reply to because I think it quite well encapsulates the groundless fears that swirl muddily around this topic. (Hall, unfortunately, seems to have chosen the quote so that she can echo these fears, rather than in order to examine them and see whether they’re actually justified.)

At about the age of 5, I was convinced I was a boy who had mistakenly been born in the body of a girl. This was in the 1950s, so there was never any discussion of my feelings, and obviously I never heard of “gender dysphoria.” By the time I was an adolescent, these feelings had disappeared. Parents who rush to allow children to “transition” when they are young may be harming their children more than if they just waited to see if the child still felt that way when they got a little older.

It’s not totally clear what this commenter thinks would have happened if she had attended one of today’s gender dysphoria clinics; in fact, I suspect the commenter isn’t clear herself on what she thinks would have happened. However, she does clearly have some kind of significant concern about the possibility that she would somehow have ended up rushing, or even being rushed, into an overly hasty decision to transition that would have then turned out to be the wrong decision for her. And this is the concern that normally comes up in these discussions.

So let’s look at what actually does happen.

Let’s imagine for a moment that gender identity and gender dysphoria research had been seventy years ahead of where it actually was, so that the guidelines and clinics we have today were available in the ’50s. Let’s imagine that this woman’s feelings about her gender, back when she was 5, had led to her referral to the kind of gender identity clinic that’s available to transgender people now, where she could have been assessed and managed under the guidelines that exist for children with gender dysphoria in the present day. What could we expect her experience there to be?

To answer this, I turned to the international guidelines on gender dysphoria management; the World Professional Association for Transgender Health’s Standards of Care. They can be downloaded for free here; the sections which I drew on for this post are on pages 14 to 19. My other main source was the study Desisting and persisting gender dysphoria after childhood: A qualitative follow-up study (Steensma et al., Clinical Child Psychology and Psychiatry, 2011; 16(4): 499 – 516). This is a key study on the topic of children who do lose their initial ‘wrong gender’ feelings after childhood, and factors that differentiate them from children with gender dysphoria that persists into adulthood. The abstract is available online at that link; the full study can also be downloaded for free there.

Based on the above information, here is what actually would have happened for this commenter if she’d visited a well-run modern-day gender identity clinic in her childhood.

First of all, she’d have had the chance to meet with supporting and non-judgemental professionals who would have explored her feelings about gender with her, without trying to push her one way or the other. They’d have taken a full and detailed look at what was going on in her life generally; at how her family life, her school life, and her social life were going, and whether there were problems there. They’d assess her for signs of mental health problems such as depression or anxiety, and, if such were found, treat them appropriately. They’d have provided support for her and her family, as well as pointing her in the direction of other resources that could help.

They’d have discussed whether or not she wanted to try any parts of what’s known as ‘social transitioning’ – living as one gender without making any physical changes. For example, she might want to try having clothes, haircuts or toys that were traditionally viewed as ‘for boys’, or maybe even move on to being called by a boy’s name and/or referred to as ‘he’ instead of ‘she’. If so, there would have been some careful discussion of what implications this might have in terms of how other people would react and treat her, and it would also have been made clear to her that this was an experiment, not the start of an irreversible journey; if she tried these changes and found that they made her more uncomfortable rather than less, it would be absolutely fine for her to reverse them at any point. She might have been offered the option of trying these changes only on holiday, where it would be easy for her to stop them without pushback from people who knew her. Of course, on discussion it might have emerged that she didn’t feel comfortable with trying any of these changes; that would also have been fine. The goal over this time would be to help her explore her feelings about her gender in ways that would be fully reversible should those feelings change.

It’s not clear from her comment when her beliefs about having the wrong-gender body faded, although clearly it was at some point between age 5 and when she hit puberty. If those feelings did persist over the next few years, the clinic would have been particularly on the lookout for how she reacted to the run-up to/early stages of puberty. This is because, in the Steensma et al study I linked to above, this showed up as the stage that differentiated persisters (those children whose gender dysphoria feelings continued) from desisters (those children who grew out of them). Desisters reported that, during this stage, they found themselves coming more to terms with their bodies, and that pubertal changes were, overall, a positive factor that helped reconcile them with the idea of being their birth gender. Persisters reported the exact opposite; their feelings of gender dysphoria became much stronger, and pubertal changes were extremely distressing for them.

This woman, of course, was clearly a desister. From her wording (‘By the time I was an adolescent, these feelings had disappeared’), it sounds as though, in her case, the initial feelings of gender dysphoria faded before she reached puberty. When that happened, her family would have been able simply to discharge her from the clinic.

That’s it. That’s what would have happened. That’s what happens to children today who are referred to gender identity clinics with feelings that turn out to be temporary; they get to talk those feelings over with supportive and non-judgemental medical professionals who also do their best to find out about any other problems in the child’s life that may need help, they’re supported in reversible ways of experimenting with gender identity if and only if they so wish, and they can stop follow-up whenever they feel the feelings have faded.

All this business about letting children wait a bit longer/not rushing them into transitioning/being aware they might feel differently as they get older? These are not mysterious extraordinary concepts that have somehow never occurred to the doctors who work in this field. These are fundamental principles of good care for children with gender dysphoria. This is what is already happening for children with gender dysphoria. So, when next you hear someone raising concern about how young children with gender dysphoria should be allowed to just wait a little longer, or whatever the concerned phrase is… then be aware that this is exactly what’s already happening.

BMJ article on gender dysphoria issues

A few weeks ago, the British Medical Journal carried two educational articles about management of gender dysphoria in the non-specialist setting (one written by a gender dysphoria specialist with input from patients, and one a collection of advice from transgender people). Transgender people can have some significant problems with healthcare both for their gender dysphoria care and for their general care, so, although this only affects a small minority of the population, this is an issue it’s important for me as a GP to be aware of.

I have a separate site where I keep the notes I make on any medical articles or educational modules I read, in order to refer back to them later. This time, however, I thought I might post them here; after all, transgender health care is an important topic to many people here. Here are the points covered by the articles:

  • When someone comes to you expressing problems with gender identity (‘you’, here, meaning GPs, not the general population), offer them referral to gender identity services ASAP. Waiting lists are horrendous, so, if a patient does want to explore the possibility of transitioning, the sooner they get on the waiting list to do so the better. As a GP, I’m very schooled in the approach of “let’s wait a bit and see how this goes with time”, and for a large proportion of the patients I see that is perfectly appropriate, but gender dysphoria is one of the situations where it isn’t. The gender identity services themselves will be the ones who can offer expert assessment and help patients reach an informed decision regarding transitioning. (As one of the patients in the second article pointed out, gender identity treatment has one of the highest satisfaction rates of any branch of medicine. Puts the desistance myth into perspective, doesn’t it?)
  • Take the trouble to find out what name and pronouns your patient wants to use, and use them. That, frankly, is just basic courtesy. However, be aware that, for safety reasons, a patient may need letters to be addressed to their old name for the time being (if they’re living with family members who are against the transition and unsupportive or even threatening over it). Use their new name and pronouns when discussing them with other healthcare personnel; it’s a way of respecting their gender even when they’re not there.
  • Transgender people who haven’t yet accessed proper treatment may be self-medicating with hormones purchased online. Ask about this and advise that it does carry risks and that ideally it should be stopped until the person is seen by the gender identity clinic. Of course, given the waiting lists, there’s a gulf here between ‘ideally’ and ‘bearably’. If a person can’t face stopping medication for the time it’ll take to get seen, advise them to let us know of side effects and to let healthcare practitioners they see know about the medication.*
  • Suggest informal on-line support groups while a patient is waiting to be seen. Tranzwiki.net was the example given.
  • Some surgical treatment can take place locally, such as hysterectomy/oophorectomy; however, do bear in mind that a person who has become visibly male may feel very awkward about attending a gynaecological clinic. One possibility suggested was that a patient in this situation could get a woman to accompany him to the clinic, if possible, so that he wouldn’t stand out as a solitary male in a sea of female patients.
  • Screening can raise unexpected problems. For one thing, gender-based automated systems in the NHS are not set up to deal with patients who’ve changed gender, and so they may not be called automatically for screening they should actually have (aortic aneurysm screening for MTF, cervical screening for FTM who still have a cervix in situ). Remember that the form that goes with the sample will need to clarify what’s going on so that the lab doesn’t simply assume that the cervical smear sample labelled as coming from Mr Fred Jones, M, to be a mistake. For another thing, the screening tools for things like risk of cardiovascular events or fractures include gender as one of the factors used to calculate risk, and the data on transgender people in this context simply doesn’t exist. It’s necessary to do some common-sense estimating and explain the uncertainties to the person in question.
  • On the topic of screening, the article also stated that AMAB women do not need routine mammography as, in the absence of progesterone, their risk of breast cancer is too low for it to be needed.
  • Conversely, an AFAB male who still has breasts should be advised to have mammography if in that age group, but may find it distressing to discuss the matter. The article ‘I am your transgender patient’ suggested that talking about ‘chest’ rather than ‘breasts’ might be easier for some men in this situation.
  • There isn’t any single rule or guideline for how transgender people feel about their gender, their identity, or their gender-specific body parts. They might be very distressed by some, quite comfortable with others. It’ll vary from person to person. This is one of the (many) situations in medical practice where you have to be sensitive to the person’s cues and willing to find out their wishes and to follow their lead.

 

*This, of course, raises the question of whether GPs in that situation should prescribe hormones themselves rather than leave the patient with the risks of buying hormones on-line. This wasn’t covered by the article. WPATH guidelines do touch on the possibility of ‘bridging’ prescriptions, but it’s a complicated issue that carries the risk of major medicolegal problems for the GP if they prescribe outside their area of expertise, and there are very good reasons why GPs would typically be unwilling to do this. This is beyond the scope of this particular article, which is why I haven’t gone into it further here.

Fact-checking transgender treatment myths, Part 2 – the David Reimer fallacy

In my last post, while discussing an inaccurate claim about transgender treatment recently made by Lenny Esposito on the Come Reason blog, I promised to come back to his past post Today’s Snake Oil Includes A Scalpel: The Damaging Treatment of Transgenderism for some much-needed fact-checking. In that post, Esposito claims that gender reassignment therapy is ‘a dangerous falsehood that many times proves deadly to the patients that should have been helped’, and goes on to cite various pieces of evidence to make a superficially convincing case for this claim. However, this is extremely misleading; Esposito’s post not only contains several significant errors and fallacies, it also ignores all the research that actually shows gender reassignment therapy to be beneficial overall for nearly all the people who opt for it. Some proper fact-checking is clearly sorely needed here and, with apologies for the delay in getting back to it, here we go.

There’s quite a bit in his post to discuss, so I plan to break it down into several short posts dealing with each point separately. First up, his discussion of David Reimer’s story.

[I]n 1967 he [Dr John Money] sought to change a two-year-old boy whose genitals had been damaged by a botched circumcision into a girl, reassuring the parents that the child would grow up never knowing the difference. But, as the Los Angeles Times reported, “the gender conversion was far from successful. Money’s experiment was a disaster for Reimer that created psychological scars he ultimately could not overcome.” David Reimer committed suicide at the age of 38.

While it’s not clear to what extent Reimer’s suicide was a response to his history of gender surgery and to what extent it was related to other significant problems in his very troubled life, there is no doubt at all that the gender conversion attempts performed on Reimer were, indeed, psychologically disastrous for him and contributed hugely to the distress in his life, and it is very likely that they played at minimum a significant role in his final tragic end. However, there’s a big problem with using that as an anti-gender reassignment argument: Reimer wasn’t transgender.

As Esposito himself states, Reimer was a boy who was reassigned to be raised as female after a badly botched circumcision operation destroyed his penis and John Money (who was hugely influenced by his wish to prove his particular theory about gender fluidity) convinced his family that raising him as a girl was the best way to salvage the matter. There were never any claims that Reimer was transgender. From a very early stage he clearly knew he was male and wanted to be male.

Now, of course, Reimer’s situation was unique and there are limits to how much of a conclusion we should draw from that one story; but it does strike me as notable that what we have in Reimer’s story is the story of a person being raised as female who knew all the time, on some level, that he should actually be male.  In other words, the experience that a transgender man [a person born into a female body but with an inner gender of male] grows up with. And he found it devastating and destroying. That really doesn’t strike me as a good argument for trying to convince someone who identifies with one gender that they’re actually the other.

Of course, I have little doubt that Esposito and his followers would argue that a transgender man’s experience of distress over growing up in the wrong body shouldn’t be treated in the same way because he isn’t ‘really’ a male (by which they would mean that he’s not chromosomally male, or possibly that he wasn’t born with a penis – I’m not quite sure what, specifically, their criterion is). But, whichever way you look at it, it strikes me as pretty illogical to take an example of someone who found it deeply distressing to grow up with an assigned gender that his own inner certainty was telling him to be wrong, who could not refuse his need to live as the gender that matched his inner knowledge of himself – and use that to bolster your claim that people who are deeply distressed at growing up with an assigned gender that their inner certainty tells them is wrong should not be allowed to live as the gender that matches their own inner knowledge of themselves.

Misinformation about gender reassignment therapy (part 1)

One topic that’s shown up on Christian blogs a lot lately (because it’s been in the mainstream news a lot lately) is that of transgender people and gender reassignment surgery. I’ve been reading a lot of dubious claims from these sorts of articles, which have been ringing my Fact Check Alert bell big-time. I don’t know a great deal about transgender issues, but, as a GP, I do know that medical opinion supports the availability of gender reassignment as a treatment for gender dysphoria. So, when non-medical groups with a heavy religious-based agenda in the matter try to claim that gender reassignment is bad for transgender people and we should be banning it in their interests, that rings alarm bells for me and I want to look at the evidence.

The latest such post that I saw was Bloodletting and the Modern Trans Movement, on the Come Reason blog by Lenny Esposito. Esposito argues that because doctors once used to believe in treatments such as bloodletting which are now discredited we should therefore assume that medical advice to provide gender reassignment therapy for transgender people is similarly incorrect. Or something like that, anyway. That of course is just a logical fallacy (by the way, if anyone knows the official name for that logical fallacy feel free to shout out – I don’t keep track of logical fallacy names myself) but the bit that hit my Fact Check Alert button in this post was this:

I’ve pointed out before how we have fifty years of data under our collective medical belts on gender reassignment surgery and we know that the suicide rate for those suffering from gender dysphoria is as high after sexual reassignment surgery (SRS) as it is prior to transitioning.

The link Esposito gave there is to a post he wrote last year titled Today’s Snake Oil Includes a Scalpel: The Damaging Treatment of Transgenderism, which rang my Fact Check Alert bell several more times and needs a post or several of its own to discuss, which I fully plan to do. In the interest of speed and clarity, I’m going to leave that to further posts rather than try to cover everything here. What it did not do, even with the cherry-picked and misleading evidence it cites, was support Esposito’s statement that suicide rates are as high after gender reassignment therapy as before. The post cited one study showing much higher suicide rates among transgender people post-reassignment than in the general population (though without pointing out that these high suicide rates were seen a few decades ago when anti-transgender bias was worse than it is now, and that they don’t show up in recent years), but nothing comparing rates of suicide in transgender people pre- and post-gender reassignment. So, whatever Esposito may have convinced himself he ‘knows’, he hasn’t in fact demonstrated anything of the kind.

So, I did a bit of digging around to see whether any such statistics do exist, and, as far as I can find out, they don’t. I did find this report on rates of suicide attempts in the transgender population overall, which is frightening; transgender people were almost ten times as likely as the general population to have attempted suicide at some point. Not surprisingly, this was strongly linked with experience of discrimination, bullying, rejection by family, or even outright violence, making it clear that, for those of us concerned about suicide risk among transgender people, one of the most important things we can do is to work to increase transgender acceptance. (Which, frankly, doesn’t seem to be a strong point among conservative Christians such as Esposito.) And this article cited studies also indicating markedly increased suicide rates in the transgender population (and, again, cited evidence that showed this to be linked to experiences of discrimination and family rejection).

However, I couldn’t find anything giving comparative figures for suicide rates, or suicide attempt rates, in pre-transition and post-transition transgender people. Which isn’t too surprising, by the way, since it’s the sort of question on which it’s hard to get data; but it does mean that it is not correct to state that we ‘know’ the suicide rates to be as high after gender reassignment as before. We know nothing of the kind.

So what information is available on how gender reassignment affects transgender people? Looking, I found this article reviewing the existing evidence as to how gender reassignment affects the mental health and quality of life of transgender people overall. According to the abstract, the authors of this summary found 28 studies that followed transgender people through gender reassignment therapy (surgical and/or hormonal) comparing their mental health after the procedure with before. What they found was that, psychologically, the majority of people were better off after gender reassigment.

Pooling across studies shows that after sex reassignment, 80% of individuals with GID reported significant improvement in gender dysphoria (95% CI = 68–89%; 8 studies; I2 = 82%); 78% reported significant improvement in psychological symptoms (95% CI = 56–94%; 7 studies; I2 = 86%); 80% reported significant improvement in quality of life (95% CI = 72–88%; 16 studies; I2 = 78%); and 72% reported significant improvement in sexual function (95% CI = 60–81%; 15 studies; I2 = 78%).

So, no matter how hard conservative religious groups or other anti-transgender groups try to spin evidence to make it look as though it supports their cause, the evidence is in fact that the best thing to do to help transgender people is a) to eliminate prejudice and discrimination against them, and b) to make gender reassignment available for those who, after counselling, want it.