Transgenderism: Not A Choice September 23rd, 2022
GENDER – two components
Gender identity– a person’s basic internal sense of being a man,woman or another gender
Gender expression – conveyed through appearance, behavior, personality styles; often culturally defined as masculine or feminine. Variable to individual.
Sex – biological construct based no anatomical, hormonal, genetic basis (assigned at birth based on anatomy)
Sexual orientation – relates to types of partners an individual is attracted to romantically and sexually
Disorders of Sexual development (DSD) – medical conditions (Klinefelter Syndrome, XXy; Turner Syndrome,45XO; Androgen Insensitivity Syndrome) in which anatomical, chromosomal, gonadal sex varies from typical male/female;
INTERSEX Transgender – is an umbrella term for people whose gender identity or gender expression does not conform to that typically associated with the sex to which they were assigned at birth. Some who do not identify as either male or female prefer the terms, genderqueer, gender non-binary, gender-neutral, agender, gender-fluid “cisgender” describes people who identify as the gender that matches their assigned sex. Transfeminine is a term for a person assigned male at birth (AMAB) identifying as a female transmasculine is a term for a person AFAB that identifies as male.
Gender diversity is NOT a mental illness – American Psychiatric Association, American Academy of Child and Adolescent Psychiatry, American Academy of Pediatrics, World Professional Assoc for Transgender Health, Society for Adolescent Health and Medicine, AAFP, ACOG, American College of Physicians and WHO.
Growing medical evidence supports a neurobiological basis for gender diversity and many scientific studies are ongoing to further research the best way to care for transgender people. Current estimates are that there are 2 million transgender people in the U.S alone. Transgender individuals have existed in every culture and time period throughout the world. Unfortunately, gender non-conforming individuals suffer a lot of discrimination and condemnation in the U.S. and around the world currently. We need to understand gender diverse individuals so that we can better care for them as a society. Gender non-conforming people are more likely to be the victims of violence, murder, and more likely to suffer from anxiety and depression and to commit suicide due to the lack of support and acceptance and discrimination. Currently many states are passing laws that restrict medical care and insurance coverage for gender-affirming care. Texas has made laws that allow prosecution of parents who seek gender-affirming treatments for their children. Last month Florida became the ninth state to bar trans people from using Medicaid to help pay for gender-affirming care.
Children as young as 18 months have articulated gender expression and identity preferences. Research shows that children recognize their own gender and gender in others starting when they are very young. You may notice children behaving in ways typical of their gender as early as two or three years old. By the age of five, most children can identify the gender of other people. Children whose gender identity doesn’t match the gender they were assigned at birth may behave in ways that don’t match their assigned gender. For example, a child who was assigned female at birth might prefer to play with “boy toys” like trucks and tools. This can start when children are toddlers. By early grade school, children may be able to express that their internal gender is different than the one they were assigned at birth. This is known as gender dysphoria. Gender dysphoria is the distress someone feels when there is a difference between their gender identity and the anatomy of their body. People with gender dysphoria are called transgender. In a 2020 study of transgender adults, 73% of transgender women and, 78% of transgender men reported that they first experienced gender dysphoria by age seven. Typically, gender dysphoria gets more serious if the person continues to live in the gender they were assigned instead of their internal gender identity. Gender dysphoria is upsetting to children who experience it. It is not a phase and continues indefinitely. Experts say children have diagnosable gender dysphoria if they have experienced significant distress about their gender for at least six months.
They also exhibit six or more of the following behaviors:
-Expressing the desire to be the other gender or insisting that they are the other gender
-Strong preference for wearing clothes of the opposite gender
-Strong preference for make-believe play or fantasy play where they role-play the opposite gender
-Consistent preference for toys, games, or activities typically preferred by the opposite gender
-Consistent rejection of toys, games, and activities typically preferred by their assigned gender
-Primarily chooses playmates of the other gender
-Expresses dislike of their sexual anatomy
-Expresses a desire for physical sex characteristics of the opposite gender
In teens, gender dysphoria symptoms must be present for at least six months as well as six or more of the following:
-Able to express a sense of disconnect between their preferred gender and their physical sex characteristics
-Consistent desire to change their sex characteristics to those of their preferred gender
-Consistent desire to be their preferred gender
-Consistent request to be treated as their preferred gender
-Strong conviction that their emotions and thoughts are those of their preferred gender
More and more experts agree that gender isn’t as simple as male and female. They believe that those two gender identities are the endpoints of a spectrum of possible gender identities. Some people’s gender identity falls in the middle of that spectrum. They don’t embrace either the identity of male or female. These individuals may describe themselves with words like non-binary, genderqueer, gender-non-conforming, or androgynous. They may use they/them pronouns or newer pronouns such as “zie”.
Growing medical evidence supports careful listening, thoughtful discussions and patient centered approaches to gender exploration. lt is important for families to listen to a child who experiences gender dysphoria and supports the development of their gender identity. Potentially HARMFUL approaches – wait-and-see (assumes gender is binary and becomes fixed at a certain age – pathologizes gender fluidity; redirection (positive reinforcement to align with ASAB) reparative or conversion therapy
For young children, decisions must be made to create safe environments that promote healthy growth and development.
Gender non-conforming children may or may not continue into adolescence or adulthood with transgender identities or gender dysphoria. Studies note that increased intensity of gender dysphoria predict future transgender identity. Some recent research reports good mental health among transgender children supported in their asserted gender.
All children are more likely to have a healthy self-image, self-esteem and general well-being when their authentic identity is recognized,supported and loved.
Early on, transgender children may undergo social transition:
Social Transition – changing external appearance (clothes, hairstyle) and possibly name and pronouns to match internal gender. Social transition and affirmation among children age 6 yo 14 decreases anxiety and depression It is important to tailor the medical, mental health care and approach to each child individually. GNC youth can experience trauma at onset of puberty. Often gender dysphoria coincides with puberty onset. There is often a high frequency of mental health challenges including anxiety, depression, social isolation, self-harm and substance use. Gender dysphoria present since childhood that intensifies with the onset of puberty rarely subsides.
The next step in treatment of gender diverse individuals might be to suppress puberty with hormones. This is a reversible treatment pioneered by VU university Medical Center Amsterdam – gonadotropin releasing hormone (GNRH) analogues to delay puberty safely for decades. This has been going on previously in patients with precocious puberty – medical condition of too early onset of puberty. Preliminary results show behavioral problems and general psychological functioning improve. Not for long-term use as it affects bone mineralization.
The next step in gender-affirming treatment is treating the individual with exogenous hormones that help align them with their felt identity. The Endocrine Society guidelines start gender-affirming hormones about age 16. Some specialty clinics/experts recommend decisions be individually determined (all therapies currently require parental consent under age 18). Testosterone or estrogen or similar hormones are administered to patients and the hormone levels are monitored carefully. This treatment is partly irreversible and has more side effects. Sterilization is one potential risk and the patient may be able to consider preserving fertility before starting treatment but this can be very costly. Endocrine Society Guidelines and World Professional Association of Transgender Health currently recommend that gender-reassignment surgery be deferred until age of 18.
The important take away here is that we need to listen to transgender people. They alone understand the way their body and mind work and we need to support and understand their lived experience. No matter what decisions are made medically by the patient, it is their decision to make and the medical community and society at large should support them and offer them respect and consideration to help them live their full, best lives.
A joint statement in April 2021 from six major medical associations including the AAP noted the following:
Our organizations, which represent nearly 600,000 physicians and medical students, oppose any laws and regulations that discriminate against transgender and gender-diverse individuals or interfere in the confidential relationship between a patient and their physician. That confidentiality is critical to allow patients to trust physicians to properly counsel, diagnose and treat.
Our organizations are strongly opposed to any legislation or regulation that would interfere with the provision of evidence-based patient care for any patient, affirming our commitment to patient safety. We recognize health as a basic human right for every person, regardless of gender identity or sexual orientation. For gender-diverse individuals, including children and adolescents, this means access to gender-affirming care that is part of comprehensive primary care.
Further, we strongly oppose any effort to criminalize or penalize physicians for providing necessary care for their patients, Physicians must be able to practice medicine that is informed by their years of medical education, training, experience, and the available evidence, freely and without threat of punishment. Patients and their physicians, not policymakers, should be the ones to make decisions together about what care is best for them.
You can also reach out for help to trusted national organizations. These include:
–PFLAG offers resources for families and friends of trans people, and focuses on building a network of allies in communities across the country. https://pfag.org/
–The Trevor Project has trained counselors to help young people who are in crisis, feeling suicidal or in need of a safe, judgement-free place to talk. Call TrevorLifeline (1-866-488-7386) or text START to 678-678 https://www.thetrevorproject.org/
–Trans Lifeline offers direct emotional and financial support to trans people in crisis. It was created for the trans community, by the trans community. If you are in crisis, call the Trans Lifeline 1-877-565-8860 www.translifeline.org
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