Flat White

Transgender: born this way?

14 July 2019

6:10 PM

14 July 2019

6:10 PM

In April, Tasmania legislated birth certificate reforms, making gender on birth certificates optional, and removes the requirement for transgender people to have surgery in order to have their gender recognised. Earlier in June, Victoria proposed similar but less radical legislation, where children could apply to alter the gender on their birth certificate but only with the backing of their parents and a supporting statement from a doctor, registered psychologist or authorised party who can confirm it would be in the child’s best interest.

A few days after Victoria’s move, Scotland delayed legislation resembling parts of Tasmania’s and Victoria’s birth certificate reforms, because of concerns that women’s groups weren’t consulted. The Scottish proposal includes a solemn declaration option, that applicants intend to live in their acquired gender permanently, that they had already been living in their acquired gender for three months, and a mandatory three month reflection period. As such, it will remain a criminal offence to make a false statutory declaration of such in Scotland, the potential punishment for which includes up to two years imprisonment. That should deter the non-trans perverts from abusing the system.

Understandably, however, these law reforms attract controversy, with emotions thrown around in public discourse needlessly, and the facts get left behind. What are these scientific facts? More like scientific indicators, because the facts of this matter aren’t the most straightforward; the science of being transgender is not yet settled. At present, scientists simplistically agree that most human beings are born male or female and that this is sort of immutable. However, that’s not as simple as birth certificates make them out to be.

Biological sex is somewhat a spectrum: this covers body parts, hormones, and genetics, just to name a few, but not gender. The XX/XY dichotomy is a simplistic starting point for discussing bio sex. There are people with intersex conditions that fall in between the dichotomy. It’s tempting to write these people off as ‘abnormalities’ because some of them do have medical issues, but many don’t. There are a range of factors that can cause all sorts of seemingly strange things to happen, ranging from genetic (XXY, XYY, Y, X, XX with translocation, XY with deletion) to hormonal (androgen insensitivity, estradiol failure), and disruptors like dioxins.

Tetrachlorodibenzo-p-dioxin (TCDD) randomly turns some boys into girls and some girls into boys, giving rise to an intersex subgroup where, for example, the female responds like the male. Here, the male hasn’t been mislabelled as female, rather, the functional female here can do all the usual female things like gestate babies, but they respond to this one endocrine disruptor in a male way. The labels ‘real men’ and ‘real women’ are not accurate labels for anyone.

As you go further down the bio sex iceberg, you find XY people that gestate babies and XX people with penises and ovaries simultaneously. And it doesn’t stop there. On the surface, the bio sex spectrum may not seem like a big deal, given that the intersex population is at least two per cent (that’s at least 150 million people in the world though). But if an endocrinologist is exploring steroid treatment with you, or discussing treating dioxin poisoning, the bio sex spectrum could be very important. If the light’s off in your home, maybe there is a power outage. Or maybe it’s just that the lightbulb blew?

We could go deeper into the iceberg, and find XX people with female secondary sex characteristics and ovaries, but who won’t menstruate and can’t carry a child without adding exogenous estrogen. People like this often have difficulty finding good endocrinological care due to the lack of understanding that bio sex is a spectrum. Of course, there is the growing discovery of late-onset congenital adrenal hyperplasia. The default for these women has been to supplement with estrogen and/or progesterone. The treatment works for some, but for many it can cause suicidal depression.

More commonly, some men have significantly lower resting testosterone levels than other men. These men are likely to respond differently to each other to hormones or mimics/disruptors. Give these different men testosterone (or estrogen, or a bisphenol) and the results would be different. In this case, not one man is more than a man than the other. So unsurprisingly, how an intersex person identifies their gender has little (if any) to do with what they have physically.

This is not the latest fashionable elite dogma that one’s birth sex may be changed at will to the gender a person chooses to affect. The reality is that bio sex is not as straightforward as calling it birth sex (as is conventionally the case with birth certificates), and that the science of gender identity is not yet settled. Sex is more than just what appears at birth, and whilst babies can be accurately recognised at birth for what they appear to be, boys or girls, it’s more complicated than that.

If you’re looking for a peer-reviewed study that gives evidence that gender is independent of birth sex, you won’t find it, because that’s not how scientific research works. You won’t find a unified body of study that presents a specific conclusion with respect to most things anyway. What you’ll find are studies that accumulate from multiple scientific disciplines over time that build towards a scientific consensus.

To clarify, gender identity should be examined in the context of psychology, neuroscience, and to a lesser extent, sociology and culture. It is at least worth noting that gender identity is conceptualised differently across different cultures in the world. How do we account for Fa’afafine, Hijras, Khanith, Native American Two-Spirit identities, and Aboriginal Australian Sistergirls and Brotherboys? The world we live in is complex, and people are complex. One should be careful in thinking that they understand our world and people.

Gender identity is like the different types of sexuality in that you can’t quantify say, heterosexuality, in tangible terms. We can see people in relationships, discuss their attractions, but you can’t really measure that with equipment. Even if you use MRI scans for brain research, do studies on whether incidences during pregnancy might be a factor, there is no scientific consensus that can be used to indicate whether an individual is for sure a heterosexual or transgender, for example. Understandably, intangible experience-based concepts are difficult for people to grasp, including yours truly.

Scientific research into transgender identity is relatively new and slow to begin with, starting with Magnus Hirschfeld, a German Jewish physician and sexologist who founded the Scientific-Humanitarian Committee in 1897. Fast forward to today, with new research happening all the time, science never sleeps, let alone settles. We’ve seen twin studies in relation to sexuality and gender identity come about, and science has moved beyond the nature vs nurture debate. Literature has started to move us towards higher confidence that transgender identity has a biological, psychological and to a lesser extent, sociological basis.

At present, the literature points in the direction that being trans is likely to be innate, that gender identity is usually known by ages 3-5. Even Kenneth Zucker, an American-Canadian psychologist and sexologist who’s (in)famously fallen out of favour with the trans community, has agreed that at age 3, children begin to self-label and form their gender identity. He further elaborated in a 2015 CAMH Gender Identity Clinic for Children Review, that at age 15, the gender dysphoric child’s dysphoria will most likely to persist, 70 per cent-80 per cent to be specific. As an authority in North America on this subject matter, he was known to prescribe puberty blockers and later HRT for trans adolescents.

Further, preliminary neuroscientific research has come about over the years and more recently, which indicate that the brains of trans adults and children resemble their gender identity, not their apparent bio sex. If the brain acts as a sex organ, which it does, perhaps trans people are indeed intersex. If this sounds incomprehensible, it’s because we’re currently in the middle of an explosion of brain research, which has greatly enhanced our understanding of the human mind. Stay tuned for more to come.

There is also a piece of preliminary genetic research recently which indicate that “certain ‘versions’ of 12 different genes were significantly overrepresented in transgender women”. One study published a few years ago looked at identical twins and found that when one twin is transgender 40 per cent of the time, the other twin is too, which is genetically significant. There are even case reports of twins raised apart and both coming out as trans. As such, the following should not come as a surprise:

  1. The David Reimer case.
  2. Gender is not a social construct.
  3. Said literature points in the direction that, at present, gender-affirming healthcare is the best imperfect way of clinically managing gender dysphoria at all ages.
  4. Transgender is no longer considered a disorder by the World Health Organisation.
  5. Birth certificate law reforms reflect all of the above.

On a side note, trans children should be allowed to socially transition genders, and trans adolescents should be allowed to hormonally transition genders in a careful and medically appropriate manner. Despite attempts to prove that trans children and adolescents can grow out of being transgender, the proof of that, which has been thrown around in public discourse, is flawed. Some studies seem to show that lots of young trans children change their mind. What these studies do is that they randomly take a group of children from gender clinics and follow them, only to seemingly find that most aren’t trans when they grow up. But what does that mean?

It means that a lot of these studies are just studying children, at random, that attend these gender clinics, without differentiating between those who have a gender dysphoria diagnosis, those who identify as trans, with or without diagnosis, and those who don’t identify as trans at all. All these children attended these gender clinics for a wide range of reasons, not just for gender dysphoria diagnosis. So the next time you hear the argument that “60-90 per cent of children will naturally grow out of it”, it’s because that 60-90 per cent weren’t trans to begin with. In fact, many of these 60-90 per cent are LGB(-T)QIA in some way, shape or form, just not T.

The 10-40 per cent don’t deserve to be forgotten – they deserve gender identity presentation alignment as appropriate, not denial of transition treatment. It’s worth noting that during the child’s formative years, the most rapid cognitive and emotional growth occurs. We now know that children’s physical and emotional environments dramatically impact the development of their nervous system (Ross Rosenberg, 2019). This is especially true of the brain and has profound implications for their psychological health as adults. Let’s get it right for the 10-40 per cent, and Victoria’s birth certificate reforms are trying to achieve that.

Transition treatment for both adults and children is slow and not as radical as it seems. The first step for a child, if they want to, is to let them wear whatever clothes fit their gender, and pick a name that feels right for them. It doesn’t sound like much, but it can go a long way for these children. Studies focused on just socially transitioned children have found that their mental health was almost as good as the other children. Trans children cannot go on hormone medication when they hit puberty, they can only go on puberty blockers, which is different – it only suppresses the hormone that triggers puberty.

This gives trans adolescents more time to be sure about their gender identity before puberty cannot be healthily delayed any further. Puberty blockers, which are reversible, have been used for decades for children with precocious puberty, with little negative side effects. Having gone through a second (female) puberty on hormone replacement therapy, I can attest that hormone medication is more or less safe. Like other medication, I’m at a higher risk of cardiovascular disease, but what medication doesn’t have side effects and risks that don’t outweigh the health benefits. One of those health benefits is that the gender transition regret rate is consistently less than 1 per cent, irrespective of when the transition started. That failure rate is lower than many medical treatments available out there.

Closer to home, the Royal Children’s Hospital in Melbourne, Australia, has seen more than 700 children diagnosed with gender dysphoria, and only 4 per cent of those children ‘grow out of it’. 96 per cent of those diagnosed as trans as children remained so at late adolescence. This also flies in the face of the alleged phenomenon of Rapid-Onset Gender Dysphoria (ROGD), which has been described as “gender fluidity… put into the minds of susceptible children”. The premise of ROGD is that there are cases of surprised parents who don’t notice anything odd about their child growing up, then surprisingly their child comes out as transgender during adolescence apparently due to external influences such as social media and trans friends. This phenomenon has been used in public discourse to argue that trans children and adolescents shouldn’t be allowed to transition, and, like related arguments, used to argue against birth certificate reforms.

Perhaps the parents didn’t notice anything due to unintentional childhood emotional neglect. Perhaps awareness-raising by social media and the public lives of trans people themselves is just bringing the transgender self of an adolescent out of the woodworks sooner rather than later (that doesn’t change the fact that they’re trans). It is likely that ROGD adolescents fall into the 4 per cent, but they should not be left behind. If ROGD is a real phenomenon that can stand on its two feet, then descriptive and diagnostic data must be developed so that it can be accepted by the healthcare profession.

At present, there is no consistently reliable data available on ROGD to develop effective treatment and support services for it. So the only way to draw clear conclusions about the identity persistence of trans children is to conduct prospective studies of children with gender dysphoria diagnosis. No muddying the waters. Said prospective studies are ongoing, and they indicate that the Royal Children’s Hospital Gender Service (RCHGS) is on the right track.

RCHGS developed the first national guidelines for managing the healthcare of trans children and adolescents in Australia, including recommended timing of medical transition and surgical intervention dependent on the adolescent’s capacity and competence to make informed decisions, duration of time on puberty suppression, coexisting mental health and medical issues, and existing family support. In other words, a multidisciplinary harm minimisation approach. Birth certificate reforms also aim for harm minimisation. My childhood and adolescent story serves as a cautionary tale for why blanket opposition to trans children transitioning genders is harm maximisation, not harm minimisation.

It is for these reasons that today’s Safe Schools and similar programs are well-intended, and as a school staff resource, they can be helpful for managing trans students as and when required. However, I generally don’t trust today’s schools, and that’s for reasons bigger than the Safe Schools controversies. Teachers’ unions are holding our education system back, and push non-industrial relations-related political agendas instead of helping with tackling the decline of literacy and numeracy standards amongst Australian school students. The administrators and education bureaucrats are just as unhelpful.

Unsurprisingly, these unions are dead against NAPLAN, not because it’s a struggle for children but because parents can use and do use the results to hold schools and teachers to account. Perhaps if the unions, school bureaucrats and the curriculum authors were more helpful, we wouldn’t keep seeing overexaggerated Safe Schools news items in the media. Perhaps the standards required for becoming a teacher needs to be raised. Perhaps schooling should be opened to the more parent-friendly for-profit sector to shake up the education system.

I have it on good authority that in a more conservative part of Queensland, there’s a school community where most parents initially against Safe Schools became supporters of the program. That’s because the school community got to pick the parts to teach and the more radical parts weren’t covered. They took a more awareness approach than indoctrination, hence the reason for its success. Food for thought.

On a related topic, it’s also not exactly self-evident that transwomen have an advantage over cisgender women in sports. One of my ex-girlfriends and I wrestled each other for fun once. Unlike her I’ve gone through male puberty, I do more physical exercise than she does, and I’m taller than her, yet she beat me in all of our wrestling matches hands-down. One shouldn’t underestimate the power of hormone replacement therapy, and there’s more to this debate than meets the eyeball test. We’ve yet to see a scientific consensus paper come out to ‘settle’ the debate.

In the meantime, and in light of the Hannah Mouncey controversy last year, AFLW now requires transwomen players to provide readings for their testosterone levels, as well as their height and weight measurements. Fair enough, because in boxing, for example, boxers are divided into weight classes, so a transwoman boxer is not going to be bigger than her peers. Specifically, AFLW competitors must maintain testosterone levels below 5nmol/L for 24 months, and the International Olympic Committee is considering to take a similar approach. Fair enough, because the usual testosterone level range for women is 0.06-1.68nmols/L, and for men, it’s 7.7-29.4nmols/L. These measures are more than enough to deter a non-trans man that wants to abuse birth certificate reforms to play women’s sports.

This still doesn’t change the fact that whilst people can transition genders, their genetics can’t be changed. Sports is already made up of athletes, including Usain Bolt, who have advantages for all kinds of genetic reasons different to each other. If everyone was genetically the same for each gender, people would find sports to be boring I’d imagine. In professional level sports transwomen continue to be underrepresented, so sports aren’t going to get any more exciting soon due to more trans people coming out. There is never a truly level playing field in sports, and no athlete is expected to compete against others who are identically matched in size, strength, ability or intelligence.

So the argument to create a separate category for trans athletes effectively bans them from actual competition because in most sports, there are too few trans athletes around. As a transwoman badminton player, I don’t know of any other transwoman badminton player in Australia. Who would I play against? Even if I could find a transwoman to play against in singles (my strength lies in doubles), what’s the point of that? She and I would earn either first or second place in every competition, and those medals would carry no significance, because our victories would not matter. The above is best summed up by the following analogy:

Imagine a young girl who is incredibly tall and will someday stand well above six feet. Should she pursue gymnastics or diving, her height may be a hindrance, and she will likely never score top results. Should she pursue volleyball, however, her height will be an incredible competitive advantage. After thousands of hours of hard work and training, she may even reach the Olympics.

Now, imagine a young girl who was born into a male’s body. At some point in her life, she transitions to become female, yet elements of her male anatomy remain. Should this young girl pursue a sport like gymnastics or the pole vault, her physiology may hold her back. Nobody will raise concerns over unfair advantages, should she pursue these sports. But, what if this girl chooses cycling or weightlifting or some other sport where here unique physiology gives her a competitive advantage?

Is her anatomy something to be looked at the same way society views the tall girl’s height? Or, is it something to be punished?

In light of today’s science behind what makes a trans person “born this way”, these birth certificate reforms surfacing of late were seemingly unexpected going back a few years, but in hindsight, it’s unsurprising.

This piece was originally published at https://medium.com/@danapham.au

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