The tricky business of gender identity
What lies behind the troubling rise in gender dysphoria among teenagers? And should we separate the “T” from LGBT?
Last November, a school in Brighton called Dorothy Stringer made the news when it was revealed that 76 of its pupils are either transgender or gender-non-conforming (TGNC). This isn’t as unusual as you might think. At another school, which also hit the headlines last year, 17 pupils are in the process of changing gender and many schools now have policies in place to support pupils who identify as TGNC, including more than 80 with “gender neutral” uniforms. Referrals to the Tavistock, Britain’s only NHS clinic specialising in children and young people who are TGNC, jumped from 697 in 2014-15 to 2,016 in 2016-17, an increase of 289 per cent.
In some cases, these patients will be prescribed “puberty blockers”, drugs that delay the onset of puberty. If they’re over 16, they may be offered hormone therapy so they develop the secondary sexual characteristics associated with the gender they identify with — breasts for those transitioning to female and facial hair for those transitioning to male. Older patients may even be given the option of gender reassignment surgery, provided their psychotherapist is satisfied they are genuinely suffering from “gender dysphoria” (see below).
Should we be alarmed by this trend? And make no mistake, it is a growing phenomenon. The Sunday Times reported in January that a record number of children are applying to change their gender by deed poll — seven to 10 a week. Before answering that question, some definitions might be useful, although it’s hard to be precise because the “correct” words to use when discussing this subject are constantly changing. Until 2013, gender dysphoria was referred to in the Diagnostic and Statistical Manual of Mental Disorders (DSM), the psychiatrist’s Bible, as “Gender Identity Disorder”. But it was renamed because of the stigma attached to the word disorder and it is now taboo for mental health professionals to think of it as a mental illness. (Last year, the World Health Organisation stopped classifying transgender people as mentally ill.) Nonetheless, the condition, if that’s not too inflammatory a word, is still classified as a form of mental illness in the DSM, albeit one that is defined a bit more carefully. A person who is gender dysphoric is someone whose gender identity — that is, the gender they intrinsically feel themselves to be — is at odds with their biological sex, usually referred to as “natal sex” or “sex assigned at birth” because the word biological is also controversial. This is sometimes expressed as the feeling that they were born in the wrong body. People who identify as “transgender” generally fall into one of two categories — trans male (chromosomal female, but identify as male) or trans female (vice versa). Those who present as “gender-non-conforming”, by contrast, can fall into one or more of over a dozen categories, including “non-binary”, “gender fluid”, “bigender”, “genderqueer”, “demi-boy”, “demi-girl”, and so on. At Dorothy Stringer School, a comprehensive for 11-16 year-olds, 40 of the children identify as transgender and 36 as gender-non-conforming.
So should we be concerned about the growing number of young people presenting as TGNC, particularly as some of them are opting for medical treatment? For lobby groups such as Mermaids, a transgender charity recently awarded £500,000 by the Big Lottery Fund, the answer is emphatically “no”. According to trans activists, the rise in the number of young people identifying as TGNC and seeking help at places like the Tavistock is entirely attributable to the decrease in the social stigma attached to the condition and, as such, should be celebrated. They are adamant the underlying rate of TGNC people in the general population hasn’t changed. Rather, as the taboo attached to expressing feelings of gender dysphoria has faded, those who would otherwise have suffered in silence have found the courage to “come out”. The parallels between trans youth and teenagers who identify as lesbian, gay or bisexual don’t end there.
A common mistake made by those who are new to this discussion is to assume that trans people are also homosexual, but that isn’t true — at least, not exactly. While only a minority of adolescents diagnosed with gender dysphoria identify as “straight”, it isn’t always clear what they mean by that. For instance, if a teenager who was born with two X chromosomes but now identifies as male says they are attracted to men, does that make them gay? If they’re attracted to women, by contrast, does that make them straight? Most trans adolescents would say “yes” to both questions, but for some it can be difficult to disentangle gender identity from sexual orientation. They might opt for the catch-all term “queer” to cover all bases.
One psychological theory about gender dysphoria is that it is a way for teens who don’t want to think of themselves as gay to rationalise their attraction to people of the same sex. Whether consciously or not, the theory goes, it is easier to think they are born in the wrong body than to admit to themselves or others that they are homosexual. That hypothesis has now fallen out of fashion — although some experts still stand by it and it might help explain why more sex change operations are carried out in Iran, where homosexuality is punishable by death, than any other country apart from Thailand.
Mermaids is a cheerleader for what is known as “affirmative care”, whereby any claim by a child or adolescent to be gender dysphoric should be taken at face value — and if they express a desire to transition, they should be unquestioningly supported. Mental health professionals who recommend a more cautious approach, exploring whether a young person might be feeling this way because of other, extraneous, factors before committing to a diagnosis of gender dysphoria, are looked on with intense suspicion by activists. They’re often compared to religious bigots who think homosexuality can be “cured” by conversion therapy. Indeed, anything less than an enthusiastic rubber-stamping of a child’s self-diagnosis is generally frowned upon and can lead to accusations of “transphobia” or attempting to “erase” the identity of the young person in question.
This same approach — affirming the way a child feels about their gender rather than questioning it — is recommended in the school “Toolkit” co-authored by the Allsorts Youth Project, another charity in receipt of lottery funding, which has been adopted as official policy by Brighton and Hove City Council. It is clear from the public statements made by the headteacher of Dorothy Stringer, which repeat this advice verbatim, that he and his staff have been following the guidance.
The Toolkit encourages teachers to be open-minded and non-judgmental when faced with a child who claims to be TGNC. But not “open-minded” in the sense of entertaining the possibility that the child could be mistaken. On that score, the advice is pretty dogmatic: “The important thing is to validate the young person’s identity as it is now, and support any changes that may arise as they come to explore their gender identity further.”
As part of this overall strategy, the guidance urges schools to embed “trans inclusive practice” in their teaching materials: “The curriculum should be used to explore and raise awareness of issues of assigned sex, gender identity, sexual orientation and transphobia and to make visible and celebrate lesbian, gay, bisexual and trans people. Work to challenge sexism and champion gender equality will benefit all pupils and students, including those who are trans.”
On the vexed question of whether someone who identifies as trans should be allowed into male- or female-only spaces, such as girls’ changing rooms, the guidance is also pretty unequivocal: “In most cases, trans pupils or students should have access to the changing room that corresponds to their gender identity.” If a teenage girl or her parents objects to an adolescent natal male who identifies as female using the girls’ changing rooms, the “appropriate response”, according to the guidance, is to offer “alternative changing arrangements for the child who feels uncomfortable around the trans person”. Ditto if a girl or her parents complain that it’s unfair that she should have to compete against a natal male on sports day. The child in question should be “supported to do a different activity”.
Charities such as Mermaids and the Allsorts Youth Project are not shy about invoking the 2010 Equality Act to underscore this approach. The Act identifies “gender reassignment” as a protected characteristic, meaning it’s unlawful to discriminate against someone because they have that characteristic. According to Brighton and Hove’s official guidance, a trans person doesn’t need to have done anything other than announce that they want to start transitioning to qualify for this protection. Gender reassignment, it says, is defined in the Act as applying to anyone who is undergoing, has undergone, or is proposing to undergo, a process of reassigning their sex by changing physiological or other attributes. “This definition means that in order to be protected under the Act, a pupil will not necessarily have to be undertaking a medical procedure to change their sex,” it says. “Pupils who are undergoing a social transition, for example, going by a preferred name or pronoun are protected by the Equality Act.”
The police and courts seem to share this interpretation of the law. Last year, a teacher accused of “misgendering” a trans child, i.e. refusing to use their preferred gender pronoun, was told by the police that she had committed a hate crime, a verdict confirmed by the Crown Prosecution Service. In another case, a teacher was dismissed for saying “well done, girls” to a group of natal females that included a trans student who identified as male.
However, it’s worth noting that the Equality and Human Rights Commission’s (EHRC) interpretation of the Equality Act on some of the above points isn’t as hardline as Brighton and Hove’s. For instance, it says that schools are only required to provide “appropriate changing facilities” to trans pupils, not to let them use the changing rooms of their preferred gender. So letting them use the staff changing room would be fine. Similarly, the EHRC says it is not always unlawful to restrict participation in sporting competitions to children of a particular natal sex: “Section 195 of the EA 2010 makes it lawful to restrict participation of transsexual people in competitions where physical strength, stamina or physique are major factors in determining success or failure, if this is necessary to uphold fair competition.”
The other big lever used by trans activists to encourage schools and parents to “validate” and “affirm” children presenting as transgender or gender-nonconforming, rather than question their self-diagnosis, is to flag up their high risk of suicide. Sceptical parents reluctant to approve risky and potentially irreversible medical procedures are often told “Better a live son than a dead daughter” (or vice versa) and the Brighton and Hove Toolkit claims 25 per cent of transgender students have attempted suicide and a further 25 per cent have considered it.
Is that true? While surveys do suggest the suicide rate for trans adolescents is well above average, exact figures are hard to pin down because nearly all the research evidence is contested. Susie Green, the CEO of Mermaids and herself the mother of a trans child, claims that attendees at the Tavistock have a “48 per cent suicide attempt risk”. According to the clinic, the true rate is less than 1 per cent. When an NHS psychiatrist accused her on Twitter of “making stuff up”, Green wrote: “You need to f*** off. You know nothing.”
So that’s the case for the defence. The growing number of young people presenting as TGNC should be welcomed because it reflects our society’s more enlightened, better informed attitude towards gender identity. There’s still some way to go, but as the stigma has lifted, so it has become easier for children suffering from gender dysphoria and related conditions to get the help they need. Nearly all the websites of the trans lobby groups include video testimonials from confident, attractive teenagers who’ve successfully transitioned and are now leading happy, fulfilling lives, often with their own YouTube channels where they proselytise about the benefits of “T juice” (testosterone injections) and “top surgery” (a double mastectomy). The favoured metaphor is of a chrysalis becoming a butterfly — indeed, Butterfly was the name of a recent three-part ITV drama about an 11-year-old natal male transitioning to female that received Mermaids’ seal of approval. And it’s not just the ITV drama department that echoes the views of the trans lobby. It has been so successful that its militantly affirmative approach — if you say you’re trans, then you’re trans, period — is rapidly becoming the official view, endorsed by the NHS, local authorities, the Department for Education and MPs from across the political spectrum, including Conservatives. Indeed, this seems to be the thinking behind reforming the 2004 Gender Recognition Act, which will almost certainly result in it becoming easier for people to legally change their gender. That’s an initiative of the present Conservative Government and few Tory MPs are willing to publicly dissent, partly because they’ve bought in to the idea that being trans is like being gay — some even think it’s the same thing. They are haunted by the ghost of Section 28 and don’t want to appear bigoted or behind the times.
What about the alternative position — that the number of children identifying as TGNC is something we should be alarmed about? Those who take this view aren’t necessarily opposed to transgender rights. Some are, obviously, but it would be a mistake to dismiss all the critics of the current direction of policy as Bufton Tufton types who think men are men and women are women and there’s an end to it. Many believe that children with genuine cases of gender dysphoria should be supported and, in some cases, given the help they need to start transitioning. But they worry that it’s become fashionable for teens to identify as TGNC, particularly in trendy, metropolitan areas, and that a policy of “affirmative care” — unquestioningly accepting a trans child’s self-diagnosis — is prompting some adolescents to seek life-changing medical treatment that they will later come to regret.
The starting point for these critics is usually a large dose of scepticism about whether teenagers identifying as TGNC really are as dysphoric or uncertain of their gender as they claim to be. There is no consensus among psychiatrists as to what the true underlying rate of gender dysphoria is in the general population, but few would put it as high as it appears to be at Dorothy Stringer School. In the US, the Williams Institute estimated in 2016 that 1.4 million Americans were transgender, double the number a decade earlier, but still only 0.6 per cent of the population. (That rises to 0.66 per cent for 18-24-year-olds.) Even if we discount the 36 pupils at Dorothy Stringer who identify as gender non-conforming, that still leaves 40 out of 1,653 children claiming to be transgender, which is 2.4 per cent. According to the sceptics, that’s abnormally high.
So what could be prompting these young people to come forward? One of the chief witnesses for the prosecution, albeit a reluctant one, is Lisa Littman, an American physician and researcher at the School of Public Health at Brown University. Last August, she published a paper in a peer-reviewed academic journal in which she discussed “Rapid-Onset Gender Dysphoria” (ROGD), a proposed form of dysphoria that is less authentic than typical gender dysphoria. For one thing, ROGD only manifests itself during adolescence or early adulthood and not during pre-pubescence, suggesting it’s less hard-wired than the standard condition. For another, it comes on very quickly — in some cases overnight — and the young person in question is often a member of a peer group in which one or more people have “come out” as TGNC.
Littman, who surveyed the parents of 256 gender dysphoric young people, suggested several reasons why their children’s claims should be taken with a pinch of salt. For instance, 62.5 per cent of them had one or more diagnoses of a psychiatric disorder or neurodevelopmental disability prior to the onset of gender dysphoria and many had experienced a traumatic or stressful event just beforehand. In addition, 21.5 per cent belonged to a friendship group in which one or more person had identified as transgender at the same time as them, 19.9 per cent had exhibited a recent increase in their social media/internet use and nearly half ticked both those boxes. This suggests that “social contagion” could be a factor in the spread of ROGD, in much the same way it is in the spread of eating disorders such as anorexia. Littman noted that 82.8 per cent of the children of the parents in her survey were natal females and the Tavistock reports a similar skew among its patients in the last few years.
What are we to make of that imbalance? Littman cites it as a reason to doubt that the surging diagnoses are entirely due to the lifting of the taboo. “Although a decrease in stigma for transgender individuals might explain some of the rise in the numbers of adolescents presenting for care, it would not directly explain the inversion of the sex ratio,” she wrote.
Other sceptics have made similar points. Jane Galloway, a parent and women’s rights campaigner, questions whether the growing number of children identifying as TGNC can be explained by more enlightened attitudes alone. “If that’s the case, where are the adults, the middle-aged people seeking transition?” she told the Sunday Times.
An alternative explanation suggested by the parents in Littman’s survey — apart from “social contagion” — is that claiming to be transgender is a way for otherwise fortunate teens to claim the mantle of victimhood. Nearly all the parents in Littman’s sample were white and college-educated and most were well-off. Among their children, straight white people — particularly those who are “cisgender”, which means someone who’s gender identity matches their natal sex — have become demonised as complicit in “systematic oppression”. Being trans, by contrast, is cool and au courant and enables them to enhance their status by mocking “privileged” classmates.
“They passionately decry ‘Straight Privilege’ and ‘White Male Privilege’ — while emphasising their own ‘Victimhood’,” said one parent. “To be heterosexual, comfortable with the gender you were assigned at birth, and non-minority places you in the ‘most evil’ of categories with this group of friends,” said another. “Statement of opinions by the evil cisgendered population are consider[ed] phobic and discriminatory and are generally discounted as unenlightened.”
Bradley Campbell, a sociologist at California State University and the co-author with Jason Manning of The Rise of Victimhood Culture (2018), says that claiming to be oppressed in order to boost your moral status is commonplace among American college students.
“In doing so, activists and others can create a kind of reverse hierarchy where those perceived as victimisers are denigrated and stigmatised while those perceived as victims receive aid and admiration,” he says. “This happens in a ‘victimhood culture’, and it’s very different from what you see in the ‘honour cultures’ of the past, where strength and the ability to use violence were sources of moral status. It’s clear victimhood culture has spread beyond universities, and even large corporations have adopted much of the oppression framework in employee training. It seems likely, then, that it has begun to alter the moral life of adolescents as well.”
Theories such as these are vigorously disputed by trans activists, who succeeded in persuading Brown University to stop publicising Littman’s research. They question whether ROGD is a real thing, rather than a diagnosis invented by parents trying to persuade their children that they’re not really suffering from gender dysphoria, and point out that the costs of being transgender far outweigh any superficial gains, such as an increase in status among one’s peers. Why would anyone volunteer to become a member of such an oppressed group? It makes no sense to them. On the contrary, it’s grossly insensitive since it ignores the discrimination trans people suffer at the hands of the straight, white, cisgendered population.
Critics of Littman’s research point out that two-thirds (67.2 per cent) of the parents in her survey had been told by their children that they wanted to take cross-sex hormones, while more than half said they wanted surgery. Surely, it’s implausible to think that any adolescent would embark on the process of medically transitioning, up to and including painful operations on their genitals, just because they’re swept up in a teenage fad?
For sceptics, however, the seriousness of these medical procedures is all the more reason to proceed with caution. Puberty blockers can affect bone density and, according to the NHS guidance, some of the side effects of hormone therapy are blood clots, gallstones, weight gain, acne, hair loss, sleep apnoea and, eventually, infertility. Beyond this, the long-term effects of taking massive doses of testosterone during adolescence — a standard treatment for natal females who identify as male — are unknown.
A natal female who has a double mastectomy cannot reverse the procedure, while a natal male who takes estrogen in order to grow breasts will have them for the rest of their life. Both a “phalloplasty” — the creation of a penis for a natal female — and a “vaginoplasty” — the opposite procedure for a natal male — are hard to reverse for obvious reasons.
None of that would matter so much if the patients never had second thoughts about their gender identity, but some do. They are known as “de-transitioners” and are becoming an increasingly vocal lobby in the US. American journalist Jesse Singal interviewed several of them for a cover story in The Atlantic last year and was promptly rounded on by trans activists who accused him of exaggerating the scale of the problem.
What is harder to dispute is that the vast majority of minors who identify as trans do, eventually, change their minds. (The technical term for these children is “desisters”.) According to the latest edition of the DSM, 70 to 98 per cent of gender dysphoric boys and 50 to 88 per cent of gender dysphoric girls come to accept their chromosomal sex over time. Partly for this reason, the American Psychological Association cautions against immediately embracing a trans child’s self-diagnosis, even early on, when no medical interventions are on the table, since doing so “runs the risk of neglecting individual problems the child might be experiencing and may involve an early gender role transition that might be challenging to reverse if cross-gender feelings do not persist”.
I’ve tried to be even-handed in this article, but as you can probably tell I lean towards the sceptics. There are some thoughtful clinicians who, while endorsing the “affirmative care” approach in principle, believe it’s possible to be supportive of adolescents who present as trans without rubber-stamping their self-diagnosis. Jesse Singal encountered some of these in the course of reporting his piece for The Atlantic. “I would say ‘affirming’ isn’t always doing exactly what the kid says they want in the moment,” one told him. Another said: “Our role as clinicians isn’t to confirm or disconfirm someone’s gender identity — it’s to help them explore it with a little bit more nuance.”
After surveying all the evidence, it’s hard not to agree with Jane Galloway, the parent activist who told the Sunday Times that the militantly affirmative approach borders on recklessness.
“People are embarking on medical transitions they may not need or want in the end,” she said. “I fear greatly that in 10 to 15 years’ time, we will find ourselves with a slew of young adults with mutilated bodies, no sexual function, who will turn round to the NHS and ask, ‘Why did you let us do this?’”
I have little doubt that some children identifying as TGNC have a genuine case of gender dysphoria and will lead happier, more fulfilling lives if they transition. The tricky thing is that word “genuine”. How can you tell? The DSM sets out various diagnostic criteria, but what if an adolescent failing that test insists they are dysphoric nevertheless? It’s one thing to dispute a child’s self-diagnosis of a physiological condition, but telling them their dysphoric feelings are “all in the head” doesn’t really cut the mustard. After all, isn’t the head where gender identity is supposed to sit?
One way out of this conundrum may be provided by neuroscience. Various teams of brain researchers have done MRI scans of trans people and found that, when it comes to specific areas of the brain, they have more in common with cisgender people of the opposite sex than with people of the same sex. That suggests there may be a neurobiological basis for our gender identity and it could be at odds with our natal sex.
It’s important to stress that the evidence for this is fairly limited to date, partly because there just aren’t that many transgender people around to study — not until recently, anyway — and partly because MRI scans are expensive to do and research funding is scarce.
Dr Qazi Rahman of King’s College London thinks it’s a plausible hypothesis. His area of expertise is the neurobiology of sexual orientation and he says it might be that gender identity is “innate” in the same way that being straight or gay is, something for which there’s a good deal of research evidence.
“Could people be born with gendered brains that are at odds with their natal sex?” he says. “Yes, they could. The brain systems involved in gender identity might be the same as those involved in self-recognition and recognising others and it’s possible that those systems could get swapped around in transgender people.”
However, he says it’s too soon to draw any conclusions. Some MRI scans show that transgender people have more in common with the brains of cisgender people of the opposite sex than the same sex, but some don’t. The picture is complicated if you factor in sexual orientation — and that’s assuming you can sort out how to classify transgender people as “gay” or “straight”. Finally, gender identity may be less fixed in children than it is in adults and that could influence the findings of brain imaging studies. “There isn’t really a compelling signal in the noise at the moment,” he says.
I quite like this hypothesis because it contradicts the postmodern shibboleth that gender is a “social construct”. Indeed, this is one of the main reasons for the schism between trans activists and “gender critical” feminists. If gender is rooted in biology, as some in the trans community maintain, that suggests the broad differences between males and females — differences that persist across societies, across time and even across some species — are less easily eradicated than most feminists would like. That’s not an argument for eroding women’s rights, obviously, but it means the emphasis on achieving gender parity at every level in every profession could be wrong-headed. Perhaps, at a population level, men and women do have different interests and should be allowed to pursue them without being chastised by “social justice” advocates. The idea that these gender differences might float free of chromosomal sex, at least for a fraction of the population, is a novel one and I’m still not sure what to make of it. But if the evidence for this hypothesis becomes overwhelming, we will have to accept it. (One reason to think it might be true is that some children identify as transgender from a very young age, almost as soon as they start talking.) It could also provide us with a useful diagnostic tool for deciding whether a person really is gender dysphoric. Not with a view to denying adults with “normal” brains the right to transition, but to accurately diagnosing minors presenting as transgender before discussing treatment options.
Meanwhile, schools should avoid parroting every word of the pro-trans lobby. I think it’s sensible for them to have a transgender policy, but it shouldn’t be bundled together with their policy on lesbian, gay and bisexual children — we need to separate the “T” from “LGBT”. Affirming and validating the self-diagnoses of children who identify as one of the first three makes sense, not least because there’s no attendant risk of them going on to make irreversible, life-changing decisions. A teenager can decide she’s bisexual one minute, a lesbian the next, and straight a year later. If she changes her mind, there’s no harm done. But if a natal female decides they’re transgender and then injects massive doses of testosterone and has “top surgery”, only to then have a change of heart, that would be tragic.
A majority of teens presenting as TGNC don’t go on to have these procedures and schools probably shouldn’t fret bout the growing number of children who want to experiment with different gender labels. The risk of treating them all with the same furrowed-browed intensity, nodding along gravely when they say they’re “non-binary” or “tri-gender” and handing them leaflets about transitioning, is that they’ll take what may be a temporary phase more seriously than they should. We owe it to adolescents at risk of making medical mistakes to urge caution and not just unthinkingly applaud their “honesty” and pack them off to private clinics. Schools need to find the courage to stand up to the trans activists and not let them dictate best practice in this area. Teachers would be better off trusting to their common sense.