The transgender rights movement is having a moment. In April, nearly 17 million people tuned in to watch former Olympian Caitlyn Jenner announce to Diane Sawyer on 20/20 that she is, in fact, a woman. Transgender celebrities are popping up on TV shows and magazine covers, even as cell phone videos of violence against trans people continue to pop up in Facebook feeds. (Meanwhile, Facebook itself now allows users to choose from dozens of genders for their profiles.) In his State of the Union address this past January, Barack Obama became the first president to publicly use the word “transgender”—a term that has been widely used to describe gender-non-conforming individuals since the 1980s, but one that a third of Americans still can’t define. Reproductive rights groups have even begun to excise the word “women” from their language, so as to encompass those who have transitioned from female to male: Now it’s not just women who get pregnant. People do.
Social change is always bewildering to the status quo, but this new era of gender fluidity may have sown a bit more confusion than usual. The stakes remain highest for transgender people themselves. Consider the challenges and decisions facing children with gender dysphoria—the DSM-5 designation for the anxiety individuals feel when their gender identity is at odds with their biological sex—and their parents. Historically, treatments for transgender children have involved trying to help them to become comfortable with the sex they were born into, but more professionals are now advising caregivers to allow children to live in the gender of their choosing, and even to delay puberty so they have time to decide. Fortunately, the research literature offers some clarity and guidance in how to think about all this.
GENDER DYSPHORIA IS MORE COMMON THAN WE THOUGHT…
Prevalence rates for transgenderism are hard to pin down, because the definitions are obscure, and the decision to identify as transgender is a subjective one. (Once a male has completely transitioned to a woman, is he still a trans woman?) But in recent years, clinics that cater to transgender youth have recorded increasing numbers of referrals. Boston Children’s Hospital began treating patients with gender identity disorder in 1998. Between then and 2010, the number of transgender patients increased fourfold. The clinic reported roughly equal numbers of males and females coming in for treatment.
—“Children and Adolescents With Gender Identity Disorder Referred to a Pediatric Medical Center,” Spack, N. P., et al., Pediatrics, 2012
BUT MOST GENDER-DYSPHORIC CHILDREN WON’T BECOME TRANSGENDER ADULTS
For the majority of children, gender dysphoria does not persist throughout adolescence and adulthood. In follow-up studies of children diagnosed with gender dysphoria, less than 20 percent continue to report discomfort with their biological gender assignment and may seek out gender-re-assignment services later in life. But which 20 percent? A 2013 study found that the intensity of gender dysphoria exhibited by children was tightly linked to future outcomes. Those who persisted in their gender dysphoria reported higher rates of dissatisfaction with their bodies and same-sex sexual orientation as children, and higher cognitive cross-gender identification; in statements, persisters didn’t just wish they were the opposite sex, they believed they were already.
—”Factors Associated With Desistence and Persistence of Childhood Gender Dysphoria: A Quantitative Follow-Up Study,” Steensma, T.D., et al., Journal of the American Academy of Child & Adolescent Psychiatry, 2013
IT’S TRUE THAT TRANSGENDER PEOPLE FACE SIGNIFICANT DISCRIMINATION AND STIGMA…
Research has found that if gender dysphoria does persist past the onset of puberty, those feelings are likely to stick around through adulthood. And trans people walk a hard road in America. The largest survey of trans and gender-non-conforming people to date, which surveyed 6,450 individuals, found that more than 40 percent of respondents had attempted suicide, compared to less than two percent of the general population. The majority of those surveyed also reported being bullied or harassed in school, 61 percent were the victim of a physical assault, and 64 percent had been sexually harassed.
—“Injustice at Every Turn: A Report of the National Transgender Discrimination Survey,” Grant, J.M., et al., National Center for Transgender Equality and National Gay and Lesbian Task Force, Washington, D.C., 2011
BUT MEDICAL INTERVENTIONS DO LEAD TO BETTER PSYCHOLOGICAL OUTCOMES
Puberty-delaying drugs, cross-hormonal therapies, and sex-re-assignment surgery have all been shown to be safe interventions for transgender people to pursue, and a meta-analysis of 28 studies shows that individuals who receive such treatments are psychologically better off. A 2010 study pooled data from 1,833 participants—1,093 trans women and 801 trans men—and found that sex re-assignment improved quality of life and feelings of gender dysphoria in 80 percent of individuals, psychological symptoms improved in 78 percent, and 72 percent reported improvements in sexual function. A separate study of 21 adolescents from 2006 found that hormonally suppressing puberty slowed down the adolescent growth spurt, but had little to no effect on bone mass and metabolism; in general, the patients were satisfied with the treatment. And it is completely reversible. According to the paper, “It can be considered as ‘buying time’ to allow for an open exploration of the [sex-re-assignment] wish.”
—”Clinical Management of Gender Identity Disorder in Adolescents: A Protocol on Psychological and Paediatric Endocrinology Aspects,” Cohen-Kettenis, P.T., and Delemarre-van de Waal, H.A., European Journal of Endocrinology, 2006; “Hormonal Therapy and Sex Reassignment: A Systematic Review and Meta-Analysis of Quality of Life and Psychosocial Outcomes,” Murad, M.H., et al., Clinical Endocrinology, 2010
THE BIOLOGICAL BASIS OF TRANSGENDER IDENTITY IS STILL MOSTLY A MYSTERY
People with sexual development disorders—ambiguous genitalia, for instance—exhibit hormonal and genetic abnormalities that appear to be linked to their experience of gender dysphoria. However, a 2013 review found that those abnormalities were absent or at least inconsistent in studies of trans people who did not have such sexual development disorders. Early brain-imaging studies do offer some promising leads in the search for biological markers of transgender identity, but they have yet to be replicated. They show that even before medical treatments, trans men may have masculinized brains compared to people born female. Similarly, but to a lesser degree, trans women’s brains show semi-feminized patterns of activity compared to those of people born male.
—”Sex Steroids and Variants of Gender Identity,” Meyer-Bahlburg, H.F.L., Endocrinology and Metabolism Clinics of North America, 2013
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