Gender Transition and Its Discontents

Over the years there have been salacious media reports about transgender women who choose to revert back to living as men, what we call detransition. Detransitioning happens very infrequently, but when it happens to someone who is or has become a public figure, such as Don Ennis most recently, the story takes on a scandalous air. Misinformation gets bandied about, both by the person involved and the media reporting on the reversion in gender assignment. When that happens, all of us suffer, but the trans community suffers the most. These stories trivialize our lives and the efforts we make to live them fully and authentically.

Let me start by saying that I believe that in an ideal society it shouldn't matter who you are or how you live gender-wise. It shouldn't matter whether you transition or detransition, and each person should have the right to self-determination to make her own choices. But we don't live in an ideal world.

Trans persons, like gay persons, are "born that way." While the younger generation is now claiming space between genders or negating gender entirely, I will focus only on what most Americans see as the trans experience: persons raised as boys who become women, and those raised as girls who become men.

The most important fact needed to understand this process of physical and gender transition is that the sense of oneself is innate. It does not suddenly transform as we grow, or change with puberty. It is not determined by clinging mothers or distant fathers. It matters not that Mom wanted a girl and got a boy, or that Dad punished his son for dancing. Our sense of self is inborn, and that is to be expected with a sexually reproducing species. Variations in sexual orientation, choices about procreation and the like are irrelevant for this discussion.

So while we may be raised as boys, our brains have told us we're girls, and vice versa. The process of gender transition aligns the body and social life with the mind. It is, in a very profound respect, coming home. The process has been beautifully described by women such as Jenny Boylan and Joy Ladin.

But while this is a homecoming, it's the most difficult homecoming one can attempt. Society generally does not understand or support such violations of gender behavior and role. As a result, even young trans children suffer from the signs and symptoms of post-traumatic stress disorder (PTSD). When you add in struggling that persists for years, and in many cases decades, you have people confronting a huge challenge. We often colloquially call the resulting condition "culturally induced stress disorder," modeled on PTSD.

The World Professional Association for Transgender Health (WPATH) has developed Standards of Care to assist persons in the process, and to educate society to minimize obstacles to a successful transition. Requirements for genital surgery include:

  1. Persistent, well documented gender dysphoria;
  2. Capacity to make a fully informed decision and to consent for treatment;
  3. Age of majority in a given country;
  4. If significant medical or mental health concerns are present, they must be well controlled;
  5. 12 continuous months of hormone therapy as appropriate to the patient's gender goals (unless the patient has a medical contraindication or is otherwise unable or unwilling to take hormones).
  6. 12 continuous months of living in a gender role that is congruent with their gender identity;

As you can see, these are stringent criteria. The most important one is living as one's true self for a significant period of time -- not to determine if you're really transgender (that question has been resolved in one's mind long before in most cases), but to make sure you can survive and preferably thrive as yourself. As the WPATH standards explain:

Changing gender role can have profound personal and social consequences, and the decision to do so should include an awareness of what the familial, interpersonal, educational, vocational, economic, and legal challenges are likely to be, so that people can function successfully in their gender role.

If at any time during or after this period one chooses to stop the process, that is called detransitioning. External pressures can be intense, and it may simply be imprudent for some people to continue. For others it becomes medically or financially impossible, or the tradeoffs simply may not add up. It's unfair to consider those situations failures, though after having lived closeted for decades, mired in shame, it's extremely hard to not feel like a failure. That's why detransitioning is not a panacea and often ends up creating an emotional state worse than the one present during the difficult transition process. You cannot undo the coming-out process, just as you cannot un-ring a bell.

This often unavoidable sense of failure may drive a person to fabricate a fantasy to explain away the transition altogether. This isn't surprising, as we are often looking to understand our actions, particularly those that cause a great deal of stress to ourselves and our loved ones. Some simply can't accept that they were "born that way," so they create narratives about having been stung by a bee or forcibly cross-dressed by Mom until puberty, or having suffered transient global amnesia. While we don't understand all the causes of gender dysphoria -- we know some cases are caused by genetic and chromosomal variations; metabolic differences in utero; environmental pollutants called endocrine disruptors, such as DES (diethylstilbestrol) and dioxin; or association with more generalized intersex conditions -- we do know that bee stings, amnesia, and parental behavior do not play a role. Claiming them to wall off shame and embarrassment only serves to minimize the truly difficult challenges faced by so many others and trivializes the success of those who make it through the gauntlet of societal resistance.

The bottom line is that being trans is not a choice, but the decision about how to deal with it is. People who choose not to complete their gender transition or live out their lives in their reassigned gender deserve to have their decisions respected and their efforts understood. In return, they owe us the respect of being honest about their motivations if they choose to be public, and they should understand that their public behavior can be easily misused to pathologize the rest of us.