Strange Bedfellows Perpetuate the Denial of Proper Care for Young Trans Girls

As I've reported before, there is no longer any debate within academic medicine as to the proper care of adult and adolescent trans persons. The only remaining debate revolves around children, and the issue is still contentious because there is no foolproof way to distinguish between gender non-conforming children who will grow up as transgender girls, and those who will be gay (or straight cisgender) boys.

That being said, it's a terrible shame when a reputable scientist (genetics) teams up with a discredited one to put the most vulnerable children at risk, but Dr. Eric Vilain, who has performed ground-breaking work in the genetics of human sexual development, has done just that by teaming up with the disgraced Dr. J. Michael Bailey in a recent op-ed in the LA Times. I will state up front that I agree with Dr. Vilain that there is little longitudinal clinical research on gender non-conforming boys (that no one cares much about the girls says a lot about the causes of this persistent problem), and it is difficult with any given child to determine with certainty whether that child will live happily in a reassigned gender or not. Earlier studies and anecdotal reports have left us to believe that roughly 75 percent of such boys will turn out to be gay males, 20 percent straight males and five percent trans females. But these impressions were collected during a time when few children were allowed to transition, and even fewer parents were willing to indulge their children's gender nonconformity to any degree.

Here's how Vilain and Bailey put it:

Let's take a look at the likely life trajectories of two imagined gender dysphoric boys: David, whose parents insist he stay David, and Max, whose parents allow him to become a girl, changing his name to Maxine.

In the short run, David will experience more psychological pain than Maxine. Adjustment to being a boy necessarily means accepting that he can't be a girl, something he desperately wants. Still, most gender dysphoric boys have managed the mental transition.

In the long run, Maxine will need serious medical interventions. In late childhood she will need hormones to block puberty; she will then take estrogen for the rest of her life. Eventually, she may want genital surgery. Although this surgery is usually satisfactory, side effects requiring additional surgery are not uncommon.

Each way has obvious advantages and disadvantages. We would prefer to save David the greater pain he will endure during childhood. And we would prefer to save Maxine the serious medical interventions and possible side effects.

Where is the primary problem with this analysis? When they say, "most gender dysphoric boys have managed the mental transition," they are referring to the cis gay and straight boys. Yes, they will manage the mental transition fine, because they will be feminine men. That still isn't an easy place to be in this society, but it's authentic for them, and the congruence will bring them existential peace. Max, however, is a girl.

Vilain and Bailey then paint the far more complex medical and surgical transition for trans girls in a negative light ("serious" interventions, hormones during puberty -- the wrong puberty, by the way -- estrogen "for life," surgery as simply "satisfactory" and with "not uncommon side effects.") Given the choice between a little psychological pain and the litany of medical despair what parent wouldn't choose the former? My mother summed this choice up when I told her I was transitioning, by saying, "Why couldn't you just be gay?"

Well, I couldn't, because I never was a gay man, and my authenticity lay with treating my mind and brain with respect and transitioning, regardless and in spite of the difficulties and medical risks. As a child, I suffered exquisite psychological pain, about which no one cared at all, and while I managed, I almost died on a number of occasions over the ensuing four decades.

So, Dr. Vilain and I agree (personal correspondence) that there is no definitive research, a point trans ally Dr. Jack Drescher makes frequently, but a total dependence on research when lives are at stake is unethical. Even if it's true that 75 percent of gender dysphoric boys turn out to be gay, it is also true that denying the gender dysphoric boys who are actually girls the right to transition is cruel and abusive, and too often life-threatening. Dr. Norman Spack, retired from Boston Children's Hospital, stated on the Jenner interview that such denial of care can be "catastrophic." This entire approach is built on a single assumption -- that it is worse for a boy to live as a girl for a period of time and then return to live as a boy (desistence) than to deny a trans girl her freedom to determine her life according to her wishes. That denial is cruel and unusual punishment and should be viewed as unconstitutional under the Eighth Amendment. I wouldn't be surprised if those parents, who struggled to set their trans (or gay, for that matter) children "straight" before becoming enlightened and letting their children be themselves, wouldn't wholeheartedly agree.

The saddest part is that we know the consequences of denying transition -- an epidemic of suicides that have been occurring in the trans community since at least the '60s, and continue to this day in what seems ever-increasing numbers. What we have not seen is any significant number of children who detransition and then either kill themselves from shame or bullying, or live lives tainted by the cross-gender living experience. This tells me that those who oppose gender transition in children, however rationally framed, do so out of misogyny. For them, the need to protect boys -- even gay ones -- from the shame of having lived as girls for a period of their lives far outweighs the torture of the trans girls who are denied their authentic lives until they're old enough to decide for themselves. That any parent would be complicit in such behavior says little about parental love, and far more about the profound misogyny prevalent in out entrenched patriarchal society.

For all the decades of my life before the most recent one, the medical community oppressed trans women by pathologizing gender incongruence, and using that psychopathologization ("Gender Identity Disorder") to buttress efforts at marginalization and discrimination. Many religious communities were complicit in those actions. Only in the past decade has that really begun to change, thanks to some brave pioneers, who, following in the footsteps of the prescient Dr. Magnus Hirschfeld and his student, Dr. Harry Benjamin, began to shed some scientific realism on the reality of trans women.

Also, please note that none of these concerns relate to trans men. Not that they've had it easy, but Western culture has perhaps more easily tolerated trans men than women, effectively ignoring their existence from a scientific perspective, and allowing their assimilation into patriarchal society as it threatens the power structure far less than the existence of women who have voluntarily forsaken what has been called by some feminists "penis privilege." I know few cis men who feel threatened by the existence of trans men, but I know even fewer such men who are not at least minimally uncomfortable with seriously engaging the reality of trans women.

That fear on the part of men who make up the majority of mental health and medical practitioners leads to this persistent unwillingness among even the most trans-supportive gender counselors to allow trans girls to be themselves -- because the possibility of failing to correctly diagnose a feminine child who will become a gay man causes shudders to run down their spines, in spite of the absence of any castration anxiety, since these girls don't undergo any surgical reconstruction until 18. Better thousands of trans girls suffer for several decades than even one gay boy spend a year or two living as a girl.

It's time these gatekeepers and opinion-molders challenge their own masculinity and allow all children just to be themselves.