Introduction to Transgender Issues (And Me)
What's a transgender, and why do I care about it so much?
Up to this point, I have mostly been writing as if the reader is somewhat familiar with me and is at least somewhat sympathetic to my ideas. I haven’t written any sweeping defenses of liberalism, and I haven’t released any real Transgender 101 articles here. As time goes on, that’s become a liability; the more people I reach, the more readers there are who haven’t seen things I’ve said outside of this Substack. In addition, I haven’t really done a proper “introduction to Transliberalism” type of essay, either. Since transgender issues are so important to me, let’s kill two birds with one stone.
This is an introduction to transgender issues, and to me, Sophia Hottel.
Let’s take it from the top
What does it mean to be transgender?
Nearly every person on earth is assigned a gender based on their sex when they are born. “It’s a boy!” or “It’s a girl!” Most of the time, as that newborn gets older and develops a strong sense of self, they affirm that gender they were assigned was correct (“I am a boy” or “I am a girl”). However, sometimes, somewhat rarely (but not so rarely that it doesn't matter!), at some point in that person’s life they reject the gender they were assigned. In a broad sense, this is typically what being transgender means.
What does sex mean in this context?
There are two different types of sex: the phenotype and the genotype. Phenotypical sex refers to things like reproductive organs and secondary sex characteristics such as shoulder width, breast development, and presence or absence of significant amounts of facial hair. Genotypical sex refers to sex chromosomes, whether they are XX or XY or, occasionally, something else. Sometimes we say things like “this person is a boy because they have XY chromosomes,” but that’s a bit misleading. There are people who have XY chromosomes but in every other way appear to be women. Sometimes a person’s chromosomes are not XX or XY. Perhaps most importantly, we don’t actually know most people’s chromosomes. On a day to day basis, it’s entirely irrelevant. Phenotype is much more important, although it doesn’t always “line up” cleanly; there are women with facial hair and men with breasts, for example.
What does gender mean, and how is it different than sex?
Gender involves a few different things. I’m going to discuss three of them: Gender expression, gender norms, and gender identity. Typically, “gender” refers to gender identity.
Gender expression refers to the way that a person expresses their gender. It includes things like clothing and accessory choices, hair styles, ways of speaking, and makeup usage or lack thereof. While typically men express themselves in “masculine” ways, of course there are also feminine men, so gender expression isn’t the whole of gender.
Gender norms refers to the way groups expect people of a particular gender to behave. For example, in some parts of America, women are expected to wear skirts and dresses, and men are expected to wear pants. Generally speaking, women are expected to wear makeup and men aren’t. Breaking gender norms sometimes can result in punishment, such as a parent punishing their son for putting on his mother’s makeup.
Gender identity refers to the way an individual understands themself to be a man or a woman or something else. Some people have said that gender identity is based in an internal, subjective, and unchangeable feeling of a gender, but I don’t think that’s quite right. I’ve talked to a lot of cisgender (opposite of transgender — people who stuck with the gender they were assigned) people who say they don’t really have a feeling of any particular gender. Some do, but some don’t. Instead, I think it’s more accurate to think about it as an internal, subjective feeling about gender expression and norms. That is, how do you feel about masculinity and femininity? What about being a man or a woman? For me, the former options sound miserable, while the latter options sound much nicer. For some people, both sound unpleasant.
Is gender actually unchangeable?
Yes. “Conversion” or “reparative” therapies which attempt to make a transgender person not transgender are denounced by basically every major medical and psychological organization that has spoken on the matter. They are ineffective and are associated with higher rates of mental illness and suicidality. On the other hand, transitioning is associated with lower rates of mental illness and suicidality.
What’s transitioning?
There are a couple types of transitioning. There’s social transitioning, which is moving from the social role of one gender to the social role of another. This typically involves letting people who are in contact with them know, changing gender markers on government ID, and changing up how they dress. There’s hormonal transitioning, which is either masculinizing (taking testosterone supplements) or feminizing (taking a testosterone blocker and estrogen supplements). There’s surgical transitioning, of which the main kinds are top surgery (chest masculinization), bottom surgery (such as vaginoplasty — construction of a vagina — or phalloplasty — construction of a penis), and facial feminization surgery. Not all transgender people go through all kinds of transitioning, for various reasons.
Is being transgender a mental illness?
No. In order for something to be a mental illness, it has to meet at least two criteria. First, it has to be unusual. Second, it has to be distressing or an impairment to functioning in society. A good example is delusions: In order for something to be considered a delusion, it has to be an uncommon belief, as well as one that makes it harder to engage with society. While it’s true that being transgender is rare, it is not inherently a negative thing. Lots of transgender people are content with being transgender, or have even found happiness and meaning in being transgender.
That being said, being transgender does often overlap with a mental illness called gender dysphoria. “Dysphoria” means a strong negative emotional state, or persistent uncomfortable dissatisfaction. If somebody has gender dysphoria, that means they’re persistently uncomfortable with something about them gender-related, typically the way gender stereotypes interact with sex characteristics; for example, genitals, presence or absence of facial hair, and shoulder size can be points of dysphoria. Gender dysphoria can normally be helped with therapy and transitioning.
Are transgender children actually transgender?
Probably, assuming a few criteria are met. Is the child consistently, insistently, and persistently asserting that they are or want to be a gender contrary to the one they were assigned? In other words, does a child seem to be transgender more-or-less constantly over an extended period of time, up to puberty? If they are, there is a good likelihood they’ll remain transgender. Either way, the current best practices are to provide a non-judgmental space for children who want to explore their gender. I've written more about transgender children here.
Transitioning works
Expert opinion
I’m going to provide some studies to illustrate that transitioning works, because I like to bring people in to see the science for themselves. However, there’s always a risk to trying to interpret studies yourself if you aren’t trained in a relevant field. That’s why seeing what experts and major institutions have to say is useful: They can function as a guide to help one orient themselves amidst pages and pages of obscure terminology.
Two years ago, I went through various national and international medical and psychological associations, as well as other relevant professional organizations, and compiled them into a big list. If they had anything to say about transgender people at all, virtually every single one approved of transitioning in some situation or another. In the interest of space and time, I’ll link to the ones that are most relevant to me and my audience.
American Medical Association: “Medical treatments are effective in alleviating gender dysphoria.”
American Psychological Association: “BE IT FURTHER RESOLVED that APA recognizes the efficacy, benefit, and necessity of gender transition treatments for appropriately evaluated individuals and calls upon public and private insurers to cover these medically necessary treatments” (PDF)
World Medical Association: “Evidence suggests that treatment with sex hormones or surgical interventions can be beneficial to people with pronounced and long-lasting gender dysphoria who seek gender transition.”
And under “Useful links on transgender people” on the World Health Organization website, they link to the World Professional Association for Transgender Health, a major organization which provides the influential Standards of Care for transgender people, including hormone therapy and surgeries.
It’s important to be wary of tiny medical organizations attempting to use important-sounding names to undermine the expert consensus that transitioning helps. The most egregious example is the American College of Pediatricians, a tiny organization, saying that treating gender dysphoria in children is child abuse. The American College of Pediatricians is not the (much larger and more respected) American Academy of Pediatricians, which has a “gender affirmative care model” (PDF), supporting the gender identity, expression, and exploration of children in a non-judgmental way, and taking measures to help combat gender dysphoria, if it exists.
Some studies
I can’t provide a full review of every relevant study ever done. That would take a very long time, because there’s been a lot of studies. I’ll provide a few that are relatively big:
2006, Newfield: A survey of 446 FtM (female-to-male) trans participants, those who had hormone therapy reported a significantly higher quality of life than those who had not.
2012, McNeil (PDF): A survey of 889 total transgender respondents. Transitioning in some way or another was associated with less self-harm, less suicidal ideation, better mental health, improved body satisfaction, and reduced depression. A few regretted transitioning, primarily due to complications such as botched surgeries.
2009, Murad: Meta-analysis of 28 studies with 1833 participants with gender identity disorder who underwent sex reassignment that included hormones. 80% reported significant improvement in gender dysphoria afterwards, and 80% reported an increase in quality of life.
2015, Dhejne: Meta-analysis of 38 cross-sectional and longitudinal studies. Results indicate that, generally speaking, psychopathology and psychiatric disorders in trans people reach normative values after standard therapy, such as hormones, is given.
Not every study ever done finds that transitioning helps, but the biggest and most reliable ones, as well as the studies reviewed as a collective (represented by the two meta-analyses above), show that transitioning helps with gender dysphoria.
Why do I care so much?
It’s a good question, regardless of what specifically you’re asking about.
Why do I care so much about being a woman? The fact is that I tried being a man for quite a while. I was miserable. For all the trouble being a woman has given me, it is absolutely better for me.
Why do I care so much about having all this information? I was raised to love science and think critically. In addition, I love health topics. It all comes together; it makes sense that I’d be very interested in the science on transgender issues.
Why do I care so much about sharing this information with others? Unfortunately, because transgender people are such a tiny minority, a pervasive lack of understanding easily and quickly develops into a hostile environment. There doesn’t even have to be malice for it to hurt.
Why do I care so much about it that it’s part of my identity? Every trans person has their own relationship with being transgender. As for me, I want to embrace the hand I’ve been dealt. I asked God to change me, and it didn’t happen. I don’t want to be the type which Bonhoeffer says “cannot forgive God for creating what is.”
Transliberalism
I am in love with the liberal tradition. The liberal tradition is what inspired those famous words in the Declaration of Independence:
We hold these truths to be self-evident, that all men are created equal, that they are endowed by their Creator with certain unalienable Rights, that among these are Life, Liberty and the pursuit of Happiness.
And while we’ve never quite lived up to the ideals of liberalism, I think they’re still good things to hold on to. I believe we do have rights to life, liberty, and the pursuit of happiness, rights which can only be abridged for a very good reason.
For transgender people, those rights are frequently under aggressive, unjustified attack. The most recent examples are bills attempting to limit the rights of parents seeking to have their gender dysphoric children treated by doctors who follow the medical consensus. The massive amounts of disinformation about transgender children has fueled panic about their treatment when, in reality, it is measured and based in the evidence.
In general, the liberal tradition suggests the government should stay out of one’s life unless there’s a very good reason to interfere. Up to now, transgender people have not seen this. Not so long ago, people were arrested for wearing clothes that the government deemed unsuitable for their sex. More recently, there have been attempts to restrict bathroom access, ability to update government documents, and very recently, providing guidance on how to identify homeless transgender women for the purpose of denying them shelter. These are not the actions of a small government, but rather one interested in interfering with the lives, restricting the liberty, and stymieing the pursuit of happiness of one group of people, and not another.
It’s especially unfortunate because transgender people often have been dealt an awful hand. The 2015 U.S. Transgender Survey surveyed 27,715 people across all 50 states, D.C., American Samoa, Guam, Puerto Rico, and overseas military bases. The results were depressing. 8% of respondents who had come out to their immediate family reported being kicked out of their home. 13% of those who were out or perceived as transgender in K-12 school reported being sexually assaulted. In the year before filling out the survey, nearly half reported being verbally harassed for being transgender. Nearly a third reported living in poverty, over double the U.S. poverty rate, and at the time 15% reported being unemployed, three times higher than the 5% unemployment rate at the time. And while things have progressed some, I can’t say it’s gotten much better over the past five years. I wish I could, but I can’t.
Transliberalism is about transgender issues, health, science, liberalism, and where they overlap. These topics are my passion, and they are places where I see a current and pressing need in the world.
Further reading
By me:
By people smarter than me:
Trans Kids and Teens: Pride, Joy, and Families in Transition by Elijah C. Nealy, PhD, MDiv, LCSW
American Psychological Association: Answers to your questions about transgender people, gender identity, and gender expression
World Professional Association for Transgender Health Standards of Care Version 7
9 questions about trans issues you were too embarrassed to ask by Katelyn Burns on Vox