Trans: When Ideology Meets Reality

by Helen Joyce

In her 1993 essay, ‘The five sexes’, Anne Fausto-Sterling, professor of biology and gender studies at Brown University, argued that five sexes should be recognised: male, female, merm, ferm and herm (the extra ones are, offensively and somewhat absurdly, defined as males with some female aspects, females with some male aspects and people who possess one testicle and one ovary).

It is most closely associated with Judith Butler, the most influential gender theorist of all. She claims that sex and gender are not distinct things, and that sex/gender is socially constructed.

She claims that what medical professionals do when they register a newborn’s sex is not observational, but ‘performative’. A performative utterance is one that changes social reality. Marriage vows, which turn two single people into a legal couple, are an example.

In Butler’s vision, then, medical professionals make children male or female by classifying them, and children are shaped into boys or girls, and later men or women, as they adopt the gender performance associated with their assigned sex/gender. It is now standard in transactivism to refer to people as AMAB or AFAB – assigned male/female at birth. Being trans is what happens when a person’s emerging understanding of themselves conflicts with the assignation made by the doctor or midwife – who, in effect, guessed wrong.

A remarkable example of deconstruction is provided by the definition of ‘female’ proposed by Andrea Long Chu, an American transwoman and author of Females: A Concern, published in 2019. ‘Everybody is female, and everybody hates it,’ writes Chu. ‘Femaleness is a universal sex defined by self-negation . . . I’ll define as female any psychic operation in which the self is sacrificed to make room for the desires of another . . . [The] barest essentials [of femaleness are] an open mouth, an expectant asshole, blank, blank eyes.’

Feminism is the task of centring Woman in her own life, and unpicking these associations. In the binary reason/emotion, for example, emotion is both taken to be inferior to reason because it is Woman’s domain, and taken to be Woman’s domain because it is inferior to reason. Feminists reject both propositions. A rounded life requires both, and neither need be the domain of one sex or the other.

The two elements of a binary, in other words, can continue to describe the same distinct groups as they always did, while being stripped of the associations and interpretations that situate one group as dominant and the other as subordinate. Such work is essential to imagining a better future, for women and every other group on the wrong side of a binary. But queer theory does none of it. Instead, because of gender-identity ideology, the quest for the liberation of people with female bodies has arrived at an extraordinary position: that they do not even constitute a group that merits a name.

These differ for transwomen and transmen because testosterone’s effects are so hard to disguise. A transwoman who has gone through male puberty will bear its legacy for life: a deep voice and Adam’s apple; marked facial features; facial and body hair; and an enlarged frame with big hands and feet. The legacy of pubertal oestrogen for transmen is less visible, and can be masked fairly successfully by taking testosterone in adulthood (except for breast growth, which can be undone only by mastectomy).

Far more plausible is that puberty blockers, as well as blocking the physical changes that puberty brings, also blocked the developmental process whereby gender dysphoria often resolves.

The US alone, which had just one paediatric gender clinic a decade ago, now has more than fifty offering a full range of services.

In the US, they are increasingly prescribed by non-specialists under the misleading rubric of ‘informed consent’, which means that patients or their parents sign a statement to the effect that they have researched the consequences – in other words, sign away their right to sue.

And everywhere the same pattern is evident: almost every child who takes puberty blockers progresses to cross-sex hormones. A different Dutch clinic says its desistance rate is 3.8 percent; at the Tavistock, it is 1.2 percent. The notion that puberty blockers give time for dysphoria to resolve is simply untenable. Instead, they are part of a treatment pathway that ushers children towards adulthood identifying as a trans person.

This ‘gender-affirmative’ approach is championed by the most influential clinicians. One is Diane Ehrensaft, the director of the University of California, San Francisco children’s hospital gender clinic, who sits on the board of Gender Spectrum, an activist group in San Francisco. Her book, The Gender Creative Child, is a manual for early transition. At an event in 2016 run by Gender Spectrum, Ehrensaft claimed that a toddler can indicate a trans identity to parents with non-verbal ‘gender messages’. One born male may unpop the fasteners on a bodysuit to make it look like a dress; one born female may pull out hairclips. She claims that children know if they are transgender by the second year of life – in fact, ‘they probably know before that, but that’s pre-verbal’. She has encouraged parents to socially transition children as young as three.

So parents who socially transition their children are fast-tracking them to medical and surgical transition, all the while believing that such decisions are many years away.

Some clinicians now prescribe cross-sex hormones below the former threshold of sixteen, and a small but increasing number offer surgery.

Yet, as the pressure for affirmation became stronger, Zucker was cast as a reactionary for recommending that pre-pubertal children did not transition socially, but were instead supported to become comfortable in their own sex, and progressed to drugs and social transition only in adolescence. There are still clinicians who follow this approach, he says, but they keep a low profile because they don’t want to be ‘terrorised’.

The two studies that looked at what happened when they were used to delay puberty in animals suggested this caused defects in spatial memory and increased behaviours thought to be analogous to depression in humans.

The drugs stop calcium being laid down in bones, and studies suggest a significant drop in IQ. American women treated in childhood for precocious puberty are suing the manufacturer of one puberty blocker, Lupron, alleging that it caused brittle bones, mental problems and chronic pain.

Whether blockers cause such direct harms will not be known for years. But there is no doubt about an indirect harm that will be suffered by any children who start taking them young enough to avoid puberty altogether: sterility. Cross-sex hormones cause the secondary sex characteristics of the desired sex to develop – breasts, beards and so on – but only a person’s own sex’s hormones can cause their ovaries or testicles to mature.

Many people are unaware of the impact of missing puberty on fertility. They read articles about transmen giving birth, and do not understand that those transmen must have experienced much or all of female puberty before starting testosterone. Or they hear mention of ‘fertility preservation’ – the extraction and storage of eggs and sperm – before sex-reassignment surgery and do not realise that without at least partial puberty, there will be no eggs or sperm that can be preserved.

Transmen who decide to go through female puberty and retain their sex organs to keep open the option of pregnancy may find they soon need a hysterectomy for medical reasons.

For transwomen, yet another downside of blocking puberty is that it keeps the genitals child-sized. This means there is too little skin for standard sex-reassignment procedures. More must be harvested from elsewhere to line the neovaginal cavity – Jazz Jennings’s surgeon used intestinal tissue, and had to carry out further operations when the wound reopened.

Activist groups often campaign against laws requiring sex-reassignment surgery before legal sex change, since such surgery causes sterility. But they support gender affirmation, which they seem not to understand causes sterility too.

In 2019, after some staff at the Tavistock raised concerns that children were being fast-tracked to transition, an internal review passed to Newsnight, the BBC’s flagship investigative programme, concluded that parents who preferred their child to be trans and straight, rather than ‘cis’ and gay, played a significant role in some referrals. Two clinicians said there was a dark joke among staff that soon ‘there would be no gay people left.’

If you move in liberal circles, it may seem incredible that there are people who loathe and despise effeminacy in men and butchness in women. I am afraid you are living in a bubble. There is simply no doubt that some parents’ extreme discomfort, even homophobia, about childhood gender non-conformity influences their decisions about transition. Some of them are quite open about it.

When Pakistan’s government decided recently to start funding sex-change surgery for gay males – a decision inspired by the mullahs’ belief that homosexual desire indicates that you have a brain of the opposite sex – Pink News, a British website founded to cover issues relevant to gay people, described Pakistan as ‘making history with this move for trans rights’. This is despite ample evidence that some gay men in Pakistan, and in Iran, which has similar policies, undergo such surgery unwillingly rather than risk the penalties for gay sex. These include beatings, imprisonment and even execution. A growing number of gay people are waking up to the link, however. I have heard gender affirmation described as ‘postmodern gay conversion therapy’.

These laws are so sweeping that a therapist who seeks to explore what might lie behind a child’s declaration of a cross-sex identity, or who merely tells parents that desistance is common and suggests they delay social transitioning, risks being struck off or even prosecuted.

Similar laws are being proposed and passed in other countries, including Australia, Canada and the UK. But in the UK, a pushback against paediatric transitioning is finally under way. A judicial review in late 2020 was the first time that senior judges anywhere were asked to consider whether children can truly consent to the gender-affirmative pathway, in particular to puberty blockers. Encouragingly, their answer was no.

But the judges accepted the evidence presented by Bell’s team that puberty blockers should be considered as part of a single treatment pathway that leads to sterility and sexual dysfunction.

Bell now wishes she had come across radical-feminist ideas earlier – ‘that stereotypes don’t mean anything, that it doesn’t matter if you’re masculine, that it’s your biology that makes you a woman, and there are other women like you’. The Tavistock’s approach was the opposite of what she needed, she says. ‘There was never anyone telling me to love myself and that I was fine the way I was. It was just, “change yourself and you’ll be better.” ’

Some identify as boys; others as non-binary, gender-fluid, demi-boys or suchlike. They ask to be referred to as ‘he/him’ or ‘they/them’, or by novel pronouns such as ‘xie/xir’ – in other words, as anything but female. This chapter looks at what is driving girls to abandon their sex. The story has three strands: female sexuality, modern feminism and, finally, something this group is particularly prone to – social contagion.

Early gender non-conformity and adult same-sex orientation are strongly correlated in females, just as in males; and paraphilias are an almost exclusively male phenomenon (for sources, see the further reading section for this chapter).

The changing interpretation of Bulkley’s life highlights the malign consequences of the new ideology for the still-unfinished fight for equality for women. Within that ideology, women who aspire to agency and power no longer add weight to arguments for equal rights and freedoms, but instead become men. Women are then the type of people who are content with supporting roles. In the earlier version, a resourceful woman challenged the oppression of her sex; in the new one a transman opts out of that oppression while leaving it untouched.

For the moment, I will merely observe that it is an indictment of both that the first generation of girls to be taught that womanhood can be identified out of are doing so in large numbers.

4thWaveNow in the US and Transgender Trend in the UK.

Most of the 256 parents who completed Littman’s anonymised ninety-question survey reported that their children had announced they were trans after spending more time online, after several friends had done so, or both.

Littman hypothesised that ‘social and peer contagion’ had played a role, and that adolescent cross-sex identification might sometimes be a distraction from emotional pain, like taking drugs, cutting, bingeing or starving. And she coined a name for the phenomenon: rapid-onset gender dysphoria (ROGD).

‘I now think that all, or nearly all, have some autistic traits,’ she says. Among the traits common to young people with autistic-spectrum disorders is rigid thinking, which can lead to discomfort with nuance and anyone who seems not to fit into the usual categories. If such children prefer clothing or activities associated with the opposite sex, or are experiencing the early stirrings of same-sex attraction, they may conclude that they have been misclassified.

‘It’s like if you took girls with eating disorders and gave them a belief system that validated their body hatred,’ says Ayad. ‘I’m not dealing with a child and their dysphoria; I’m dealing with a child, their dysphoria and their religion.’

‘With enough time and rumination,’ says Ayad, ‘anyone distressed can end up thinking that they’re trans.’

‘Here’s the shoeshine boy.’ Supposedly, shortly before the 1929 stock market crash that started the Great Depression, a shoeshine boy offered stock tips to Joe Kennedy (JFK’s father), and the story is often cited by market-watchers when they think that a bubble inflated by unsophisticated retail investors is about to pop.

When she first heard of the phenomenon, she interpreted it through a Jungian lens. Jung wrote about the ‘animus’, or masculine side of women, and ‘anima’, or feminine side of men. ‘The idea that teenagers were playing with this seemed wonderful to me,’ she says. And then one of her adult patients told her that these girls were getting mastectomies. ‘That completely changed the way I saw it. Jungians know that to concretise something symbolic is a very bad idea.’

As historians of medicine know, diagnoses vary from place to place and time to time, and many medical conditions are not ‘out there’ waiting to be spotted by doctors, but are shaped by them and the wider culture.

‘Mental-health syndromes are always a kind of fiction, shaped by culture and expectations,’ says Marchiano. ‘Our emotional lives, and the ways they can become disrupted, are protean.’

A new medical paradigm, therefore, may do something more profound than give doctors a new way to understand what they see: it can change what they see. Sometimes, a new condition is born – and sometimes it gains sudden popularity. The history of medicine is scattered with psychosomatic diseases that appeared, spread like wildfire and died away as medical thinking changed again.

One sign a new condition may fall into this category is that it mainly affects teenage girls and young women. They are more likely than other demographics to indulge in ‘co-rumination’: repetitive discussion and speculation within a peer group. That can lead to internalising problems, and thence to anxiety, depression and self-harm. Girls are also often more empathetic than boys, and better at reading moods, which means emotions spread faster in a female peer group than in a male one. That is why self-harm and eating disorders can run through female friends, and why historical episodes of mass hyste...

Take the ‘reflex doctrine’ of the nineteenth century, which held that a disturbance in any part of the body could cause malfunction in any other, by a ‘reflex action’ of the nerves travelling via the spine.

Some reflex theorists believed in ‘vicarious nasal menstruation’: that bleeding from the nose might replace the monthly shedding of the womb’s lining. Since nobody believes in reflex theory any more, no males turn up at gender clinics today saying that their nosebleeds follow a monthly cycle.

The idea that a child could suffer horrific assaults, immediately bury the memories deep in their psyche, remember nothing of what had just happened and grow up to be deeply psychologically damaged by this dissociation is now a commonplace of popular culture, despite the total lack of evidence that such a thing can happen.

Such conditions are known as ‘culture-bound syndromes’.