The reception to Caitlyn Jenner’s Vanity Fair cover story this week has been mostly laudable. The country, it seems, may finally be ready to approach transgender people with humanity and calm acceptance instead of snark or fear or hate. In fact, even the president continues to put a focus on transgender issues, repeatedly calling for an end to “conversion” therapies for “transgender youth.” His intentions are good, but his understanding of gender identity needs to evolve.
Gender is complicated. Gender identity development in children is even more so. Even with our ever-expanding understanding of gender’s fluidity and variance, we still err by reducing it to simple labels that do not apply to everyone. When children are developing their gender identities, over-simplifying gender can be especially harmful, as a nudge in one direction or another at this crucial phase might forever change a person’s life. Can we respect the expressions of gender-crossing children without being so “affirming” of their declarations that we accidentally steer them to a transgender path they might otherwise not want or need to take?
Let’s put a real face on this issue—a thirty-something person I’m going to call Jess. Jess and I know each other through our professional interests in advancing the rights of LGBT people. Although she was born typically female in terms of obvious biology, Jess was always what clinicians call “gender nonconforming.” Even as a young child, she gravitated toward “masculine” interests and toys. As she grew, Jess felt sexual attraction to females. Given what our culture says about gender, Jess wondered to herself if all this meant she should have a male body.
“The hardest part for me was puberty,” she recalled to me recently. Her body was feminizing even though she continued to feel “masculine” in terms of her self. Jess remembers, “I didn’t want my body to have the capacity to reproduce because it didn’t fit my concept of my gender.” She specifically dreaded having her breasts grow and getting her period.
Jess thinks that if, back then, a clinician had said to her, “you are transgender,” that might have made sense to her. She might have chosen to take puberty-delaying hormones that would have kept her from ever developing the anatomy and physiology typical for adult females. She might have followed up with some surgeries. But would that have been the right route for her?
Hard to say. She might have turned out well and happy if she had transitioned. But it’s worth reflecting on this: Today Jess identifies as a genderqueer gay person with a female body. And she’s fine with that. That means she hasn’t needed to get any surgeries and won’t need to do hormone replacement therapy, as many people who are trans need to do.
Ontario, Canada, is giving us a glimpse of what President Obama’s vision of a legislative end to “transgender conversion therapy” might look like, and why such legislation could actually harm children like the child Jess was. The Legislative Assembly of Ontario is now considering the “Affirming Sexual Orientation and Gender Identity Act,” known as Bill 77.
Bill 77 assumes gender identities and sexual orientations are all very simple---as if they are all determined at birth and easily detectable. The bill aims to prohibit any clinical practice that “seeks to change or direct the sexual orientation or gender identity of a patient under 18 years of age, including efforts to change or direct the patient’s behavior or gender expression.” That is an important goal. Doctors and clinicians should not pressure a child to be any gender or another; that is incredibly harmful. But the problem is that the bill defines “sexual orientation or gender identity of a patient [as] the patient’s self-identified sexual orientation or gender identity.”
So, under this bill’s current form, if a seven-year-old male said he feels he’s a girl, then the clinician would have to effectively accept that he’s a girl. If the child indicates a belief that s/he’s a straight girl, then even if the clinician thinks the patient might be a gay boy---that the child might, with good familial and social support, grow up to be a well-adjusted gay man without the need for sex-altering surgeries or lifelong hormone replacement therapy---the clinician must not “change or direct” the child’s understanding.
But by not “changing or directing” the child’s understanding—by “affirming” a “transgender” identity as soon as it appears—the clinician might actually be stimulating and cementing a transgender identity. (Consider by analogy how telling a girl who says she hates math that “math is for boys” can stimulate and cement that gendered self-identity.) Maybe the child who is “affirmed” will be just as well off with a transgender identity as she would have been without, but the fact is that being transgender generally comes with non-trivial medical interventions, including hormonal and surgical.
Why would a clinician ever think a feminine male child might grow up to be a gay man rather than a straight woman? The data we have indicates that a large percentage of boys who act statistically more “feminine” as children---who dress up in girlish clothing, prefer social role-play games to contact sports, are highly attentive to their mothers and aunts, and feel budding sexual attraction towards male---will end up not as transgender women, but as gay men, at least in our culture. Only a small number will grow up to be straight transgender women.
Even more concerning is what the Ontario’s bill’s approach could do to a young adult like Leelah Alcorn, the born-male transgender teenager who killed herself because her parents wouldn’t accept her identity. Imagine if Leelah had responded to parental pressure by insisting to a clinician trying to help her that she was not transgender. Under Bill 77, the clinician would have to accept the patient’s professed self-identity, even if the clinician believed that gender transition might save this patient’s psyche and her life.
Worst of all, if Bill 77 passes, it could very well dissuade many compassionate and progressive clinicians from working with gender-variant youth. That would be a terrible outcome. We need these clinicians, and we need them to follow patients’ needs, not cultural trends.
Take Jess’s case again. Although she isn’t transgender, Jess has no doubt that as a youth she needed clinical help as much as transgender youth do: “I wish someone had worked with me on body image and my relationship to my body, on how my body displays gender and how I can convey gender in a way that makes sense for me.” If that had happened, she says, she might have avoided the social withdrawal and eating disorder that ensued from her identity struggles.
Make no mistake---for a child who feels consistently and very strongly the body of the “opposite” sex is what she or he needs to survive and thrive, chemical puberty-blockers followed by gender-affirming surgery and hormone replacement therapy can be lifesaving. But for a lot of children who end up in “gender identity” clinics, the story is more complicated.
Jess says---and I agree---children who may be LGBT and/or gender nonconforming “need to arrive at the identity they will” while adults give them “the space to come to that on their own, providing supportive care along the way.” Part of that means not pressing a child to tell us what gender and sexual orientation they “really are,” as legislation like Bill 77 would seem to encourage.
Jess tells me, “In retrospect, I’m very happy having the body I have, with just some changes in how I express it. I hold internally an identity that is valuable for me, and knowing I don’t necessarily have to pick [from the typical social categories] has been very liberating.” The clinical goal, in Jess’s words, should not be to solidify labels of L, G, B, and/or T with these children, but to “avoid the harmful impacts of stigma towards this population and promote a healthy sense of self.” The outcome that should matter to us clinically is not the label the person might adopt, but the person herself.
