The very large differences between one trans person’s needs and another, which were made clear via the resource guide  Families in TRANSition, at the end of the first part of this blog on transgender youth – and were later commented upon knowledgeably by Peace in the course of some excellent exchanges between readers – draw further attention to the question of what being transgender really means.

For this, that we have to ponder what constitutes gender itself. As Robin Marantz Henig wrote for the National Geographic’s special issue, gender is an amalgamation of several elements, including our biological sex: chromosomes (those X’s and Y’s), anatomy (internal sex organs and external genitals), hormones (relative levels of testosterone and oestrogen), psychology (self-defined gender identity), and culture (socially defined gender behaviours).

What gender includes can be very confusing, though, because it depends on the context. Sexologist John Money introduced the terminological distinction between biological sex and gender as a role in 1955 (long before his now discredited recommendation of surgical sex-reassignment on David Reimer in his infancy). However, Money’s meaning of the word did not become widespread until the 1970s, when feminist theory embraced the concept of a distinction between biological sex and the social construct of gender. For the purpose of today’s discussion, we definitely need to engage with the biological side.

Intersex model Hanne Gaby Odiele is genetically male but was born with ambiguous external genitalia. At age 10 she had undescended internal testes removed and transitioned to live as a female. But she now feels this surgery was unnecessary. She says, “I am proud to be intersex, but very angry that these surgeries are still happening… It’s not that big of a deal being intersex … it became a trauma because of what they did.” According to the UN, up to 1.7% of the world’s population is born with intersex traits, about the same as the number of people with red hair.

Intersex model Hanne Gaby Odiele is genetically male but was born with ambiguous external genitalia. At age 10 she had undescended internal testes removed and transitioned to live as a female. But she now feels this surgery was unnecessary. She says, “I am proud to be intersex, but very angry that these surgeries are still happening… It’s not that big of a deal being intersex … it became a trauma because of what they did.” According to the UN, up to 1.7% of the world’s population is born with intersex traits, about the same as the number of people with red hair.

The necessity of bringing in biology becomes clear once we begin to drill down into the detail of where gender dysphoric feelings are coming from. Research into foetal growth has implicated pre-natal brain development in the womb. People who want to change their assigned gender usually have completely normal genitalia at birth in accordance with their assigned sex. In these cases there is no reason to suspect a genetic abnormality or any other unusual physical condition.

Intersex, as usually understood, is different.  An intersex person has any of several variations in sex characteristics including chromosomes, gonads, sex hormones, or genitals. Such variations may involve genital ambiguity at birth. These intersex people are the ones who used to be called hermaphrodites, a term that was dropped as it was thought stigmatising. A second type of individual has typical-looking genitals but with internal intersexed features that are not apparent. These are known medically as “occult” intersex conditions. The point is that intersexed persons have, in the same body, both male and female biological characteristics that are typically found only separately in each sex. Well-known conditions of this kind include Turner syndrome and Klinefelter syndrome. Congenital adrenal hyperplasia (CAH) is associated with a specific defective gene. There are even mosaic situations in which the same individual possesses both XX (female) and XY (male) cell types. Bizarrely, as reproduction expert Milton Diamond puts it “a person might have an arm considered male because its cells are all XY while the same person’s leg might be considered female because its cells are all XX”. Bet you didn’t know that!

It is hardly surprising that people with these clearly fundamental intersex conditions may be unhappy with their assigned sex and seek sex reassignment surgery, SRS, later on.

However, Diamond has also made the striking claim that there are significant natural in-born sex differences found between the brains of trans people and others that are sufficient “to conclude that persons with a transsexual condition are intersexed. Simultaneously it is recognized that many intersexed persons will switch from their assigned gender, yet many will not. Transsexual people are persons now also commonly referred to as… transgender persons.” Here is his explanation:

It is known that the genitals and brain develop at different times. The genitals develop early prenatally during the first 6 – 12th week and they may develop in masculine or feminine form. If the genitals develop under the influence of the androgen testosterone they are masculinized. If they are not, female genitals develop. In comparison, the brain, it is believed, develops during the latter period of pregnancy and also is subject to the influence of androgen. If there is significant androgen present at that time there will be brain masculinization, if not, there will be brain feminization. It thus is clear that the brain and genitals can develop independently and under different forces.

Thus we have a clear biological explanation for trans children’s insistence that they are a girl trapped in a boy’s body, or the other way around. They may well truly have a girl’s brain – and mind – trapped in a boy’s body or vice versa.

But this is not to say that biology is destiny. As we have just heard Diamond say: “many intersexed persons will switch from their assigned gender, yet many will not.”

This takes us straight from a biologically fundamental point to an equally profound socially grounded one. Whether anyone wants to make the switch will be hugely influenced by what is socially acceptable in any specific culture. Half a century ago in many developed countries including the UK and US, gay sex was a criminal activity and just being gay was heavily stigmatised. In that atmosphere it made sense for many gender non-conforming children to grow up thinking they might be better off if they could change sex. In those days, though, this was a choice open only to a rare few: usually wealthy, independent-minded people who could find a surgeon, perhaps in another country, willing to risk their own reputation by undertaking what was then pioneering and highly controversial surgery.

Nowadays, however, in countries where homosexuality is still stigmatised, sex changes have become an accepted way of avoiding open homosexuality. The homophobic regime in Iran, for instance, is a big fan of transsexuality. It’s a thought that should give us pause. Do we really think we should be in a rush to emulate such a country?

Why should we be leaping to accept the fashionable view that changing sex is such a great idea, bearing in mind that it requires risky measures such as hormone replacement therapy (HRT), which has potentially dangerous long-term side-effects, and extensive, difficult surgery, when for many gender dysphoric people there is an increasingly viable alternative that does not mean rejecting your body? What I mean is that people, especially the millennial generation, are coming to accept the idea that there is a “gender spectrum”. We do not need to make the binary choice of being either male or female. While it is undeniable that only a tiny proportion of the population is transgender (0.3% of adults in the US, according to one scholarly estimate, with a further 3.5% who identify as lesbian, gay, or bisexual), what matters is that there is  growing public acceptance of gender variance.

Geneticist and paediatrician Eric Vilain –  another sexnetter, by the way, like Bailey, Blanchard, Diamond, Green and Zucker – has a vision for liberating gender expression without going to all the trouble and risk of changing sex. He sees us moving towards a society that thinks beyond gender stereotypes. “I am trying to advocate for a wide variety of gender expressions,” he told National Geographic writer Henig, “which can go from boys or men having long hair, loving dance and opera, wearing dresses if they want to, loving men, none of which is ‘making them girls’—or from girls shaving their heads, being pierced, wearing pants, loving physics, loving women, none of which is ‘making them boys.’ ”

Other cultures have shown that we humans are perfectly capable of such gender flexibility.  One solution adopted by many non-western cultures is, as Henig wrote,  “where a formal role exists that is neither man nor woman but another gender: South Asia (where a third gender is called hijra), Nigeria (yandaudu), Mexico (muxe), Samoa (fa‘afafine), Thailand (kathoey), Tonga (fakaleiti), and even the U.S., where third genders are found in Hawaii (mahu) and in some Native American peoples (two-spirit).”

That said, the right course for some young people will be the fullest possible social and bodily transition. There probably should be an element of pushback from parents and the medical profession in order to test the reality and intensity of their feelings. But not too much. How much is too much? This is a question that would tax the wisdom of Solomon. But if kids pass the “insistent, consistent, persistent” test, it should be good enough, provided that the decisions in question are in accordance with the child’s maturity and ability to make informed decisions.

As I said at the outset, it is not like sexual expression, where simple willingness may be enough. A young child should have free gender expression (without having to face harsh pushback), but it would be mad to let them choose SRS at this stage. Ironically, though, as Richard Green noted in his recent London talk, referred to last time, just a few decades ago there was nothing controversial about sexual reassignment surgery for intersex children from birth onwards – as long as doctors and parents were the ones doing the choosing, which they did with sometimes disastrous results, as in the notorious case of David Reimer, who was called Bruce at birth, surgically changed (with loss of penis and testicles) after a botched circumcision to become Brenda, but reverted to living as a male called David in adulthood before eventually killing himself. This was widely blamed on his traumatic unwanted sex change; but,  as Green has pointed out, Bruce’s twin brother Brian also committed suicide, without having suffered any such trauma.

Green considers that doctors such as John Money, widely vilified for his part in the Reimer case, acted from good intentions because it was considered vital for a child’s welfare that they should appear normal, which meant they had to fit in with the only two choices available, male or female. Also, it was believed in those days that kids would accept the gender they were brought up in. The controversial element at that time was confined to sex change operations on adults: grown-up were not supposed to have such surgery: it was thought freakish and perverted. It was almost as though there was an age of consent for SRS but you were required to be below that age, not above it!

As puberty approaches, a big decision comes into view. To block, or not to block? Puberty blockers can be used in order to slow the growth of sex organs and the production of hormones. Other effects include the suppression of facial hair, deep voices, and Adam’s apples for boys and the halting of breast growth and menstruation in girls. Temporarily halting the advance of puberty in this way is a hugely important option because it gives time for youngsters to mature and think deeply about their future without finding themselves saddled with irreversible bodily developments that would make later SRS less successful. Puberty blockers, like HRT, are a form of hormone treatment, but unlike the former there seems to be little risk attached to their use. In response to a safety scare earlier this month, the US Food and Drug Administration said it was reviewing the situation but was “not aware of any new documented safety concerns with this class of drugs that should change prescribing practices or warrant discontinuation of these medications.”In fact the safety issue seems to be the other way around: not having access to them involves a substantial risk of leading to unnecessary distress that might well result in suicide or a lifetime of regret over lost opportunities.

In Britain, children can be given hormone blockers to stop puberty at the age of nine, male-to-female or female-to-male sex hormones (HRT) at 16, and can undergo a full sex change at 18. I’d say that’s more or less right in appropriate cases.

But a lot of them will not be appropriate. Where kids have been “insistent, consistent, and persistent” since early childhood that they are in a body of the wrong sex, the case for allowing puberty blockers seems overwhelming. Most gender dysphoria (GD) arises much later, though, in adolescence. In these circumstances, in the absence of any evidence of “intersex brain” or another intersex condition, caution is indicated, based on the time-honoured fundamental medical principle “First, do no harm” (Primum non nocere), as reflected in the Hippocratic Oath. It is psychologist Mike Bailey’s view that adolescent-onset gender dysphoria in natal females, especially, “has a strong social/iatrogenic component”.

This last type is being studied by yet another sexnetter, Lisa Littman, of the Icahn School of Medicine at Mount Sinai, New York, who is currently researching “rapid onset gender dysphoria”. As part of her introduction to a survey she conducted, she wrote:

We have heard from many parents describing that their child had a rapid onset of gender dysphoria in the context of increasing social media use and/or being part of a peer group in which one or multiple friends has developed gender dysphoria and come out as transgender during a similar time frame. Several parents have described situations where entire friend groups became gender dysphoric. This type of presentation is atypical and has not been studied to date.  We feel that this phenomenon needs to be described and studied scientifically.

Quite so. The is precisely the sort of social contagion (which can reverse itself as quickly as it starts) that doctors such as Ken Zucker are very wise to investigate with their patients before undertaking pharmaceutical interventions.

Bailey has identified four types of gender dysphoria, only one of them being early onset with “intersex brain” implicated.  These are: child-onset GD associated with marked gender nonconformity (both natal sexes); adolescent-to-adult onset GD associated with autogynephilia (natal males only); late-onset FTM associated with unusual sexual/gender fantasies (natal females who want to have sex with/as gay men…); and adolescent-onset GD in natal females that has a strong social/iatrogenic component.

Autogynephia is a can of worms I’d rather not open today, as it is both highly controversial and mind-bogglingly confusing. Suffice it to say that it takes us into complex interactions between gender identities and sexual orientations. The idea that sexual motivation could be the underlying driving force for wanting to change sex in some cases tends to be hotly denied. It is seen as a slur. However, for those of us who take a positive view of sex, there is no reason why it should be: a sexual motivation can be as legitimate as any other.

Finally, the future for trans youth is not just about what the medical profession recommends or the law allows. It should be about accepting and celebrating gender diversity, so that youngsters are not put under social pressure to conform to outdated gender stereotypes.