Once upon a time, one’s sex was a simple matter. No longer. As a physician, I can only shake my head in dismay at the direction of the national conversation on gender issues. We have taken a rare medical issue, mainstreamed it, and politicized it to the point of passing absurd legislation that rolls back established societal norms and makes it next to impossible to have a reasoned discussion. When will we learn?
Gender is a biologically determined feature of all sexual beings. It is not arbitrary or fluid nor is it determined by feelings or opinion polls. Even though some lower animals, such as some fish and amphibians, can change from one gender to the other, those that do harbor the biological features of both genders. You cannot extrapolate this to humans except in rare cases noted below. For humans, gender is genetically determined by the transmission of an X chromosome from the mother to her offspring and either an X or a Y chromosome from the father. If the child is XY, it is male; if XX, it is female. It really is that simple. This is not to say that errors in the biologic/genetic process of gender determination do not occur. Few things in nature are 100% without some exceptions. Humans are imperfect and errors in genetic inheritance do occur, although they are relatively rare.
The incidence of true intersex, individuals whose genetic gender and physical appearance do not line up and whose genitalia cannot be strictly classified as male or female, is a very low 0.018%, as far as we can tell. A person may possess different combinations of chromosomes, such as an XXY, XXXY, XXY, or XXX. The first two are associated with a number of obvious physical problems, mental issues, or both. XXX and XYY chromosome carriers tend to be pretty normal for the most part. Despite these errors, there is no question of gender. If you have a Y chromosome, you are male and if you don’t, you are female.
Some homosexual males may behave effeminately, but they are unquestionably genetically and physically male. The converse applies to lesbian females. Bisexual individuals can be of either sex. Such individuals are identified by their sexual proclivities; their gender is not in question.
The transgender issue is therefore not so much a discussion of biology as it is one of identity. We are talking here about a genetically and biologically normal male who believes he is female or vice versa. Now, you have left the realm of medicine and entered the area of psychology, identity, socialization, and belief. Here, there are few absolutes.
It is instructive in studying transgender to examine the problem of anorexia nervosa. This is a known medical condition which can kill an otherwise healthy person. It almost invariably affects girls. The problem is not a metabolic or anatomical defect. It is a mental condition characterized by delusional thinking. A delusion is a firmly held belief that runs counter to reality. A young woman with anorexia can be rail thin but when she looks in the mirror, she sees a fat person. She may literally starve herself to death believing all the while that she is fat. If we dealt with anorexia the way we deal with transgender, we would be encouraging this delusion, maybe even giving them diet pills or offering them liposuction!
In my own profession of plastic surgery we have a known psychological disorder called body dysmorphic disorder. In this condition, people with normal physical features see themselves as ugly or even grossly disfigured and seek repeated surgeries to correct this. The treatment of BDD is not surgery, it is psychological or psychiatric treatment.
Some have advanced the position that we should deal with teenagers struggling with gender related issues by allowing them to use bathrooms of the opposite sex and providing them with hormones to suppress their normal hormonal changes until they are old enough to have surgery to change to them to the gender they identify with. This is so ludicrous as to evoke disbelief but our culture of self and “affirmation” has gotten to the point where supposedly intelligent people are promoting such an approach.
Studies have shown that the 80% or more of gender-confused teenagers soon settle into their biological gender without further conflict. The idea that teens wrestling with gender issues should be offered hormones to delay puberty so that future gender reassignment surgery will be easier is a monstrosity right up there with eugenics and frontal lobotomies. If advocates of protecting the rights of a confused, “transgender” teen boy by allowing them to use the girls bathroom succeed, I cannot help but wonder about the rights of a teenage girl when she is told she must share her restroom with this individual. There must be a better way to deal compassionately with the latter while upholding the right of the former to exclusive use of a bathroom for her gender.
Experts in child psychology and development cite numerous examples of cases in which supposed transgender was an effort by the individual to avoid the assumed demands and responsibilities of their biological gender or to escape perceived consequences of remaining in that gender, e.g. in some cases of abuse. The solution in such cases is clearly not to change their gender but to deal with the issue underlying this.
No less of an authority than Paul McHugh, MD, University Distinguished Service Professor of Psychiatry at Johns Hopkins Medical School and the former psychiatrist in chief at Johns Hopkins Hospital ( which pioneered sexual reassignment surgery in 1965, then discontinued this in the 1970’s, only to resume recently), has weighed in on this issue. Dr. McHugh asserts the immutability of sexual gender and of the futility of trying to change such a fundamental aspect of the nature of every person. Surgery does not turn a man into a woman or vice versa; it only creates a feminized or masculine version of the opposite sex. He questions the wisdom of gender reassignment and cites a 2011 study of 324 people who underwent sex reassignment surgery with a follow up of thirty years conducted at the Karolinska Institute in Sweden, where the culture is very favorably disposed toward the transgendered. This study showed that ten to fifteen years after sexual reassignment surgery, suicide rates among the transgendered rose to twenty times that of comparable peers. That is a pretty sobering statistic.
And, what of Bruce/Caitlyn Jenner, arguably the modern poster child for the transgendered? Dr. McHugh provides some interesting insights into that situation and closes with the hope that Caitlyn will receive competent long term follow up and appropriate therapy given the admittedly guarded prognosis in transgender individuals achieving a long term, stable degree of happiness.
I think we abdicate our responsibility as physicians if we do not speak up against political correctness when it goes against good science and sound medical practice, and urge caution in moving too quickly to affirm a pathology that is rare, poorly understood, and will self-correct in most people if we do not encourage it. The forces arrayed against a medically sound approach to transgender are great. Already, state and federal governments are exploring legislation that would prevent medical professionals from providing counseling to teenagers with gender issues if that counseling “can be construed as challenging the assumptions and choices of transgendered youngsters.” Valerie Jarrett, a senior adviser to President Obama, has stated, “as part of our dedication to protecting America’s youth, this administration supports efforts to ban the use of conversion therapy (to be clear, this is to realign their thinking with their biologic gender) for minors.”
Once gender becomes a matter of opinion or belief, it opens the floodgates of confusion in what should be, 99% of the time, a simple matter. Only politicians could turn a disorder in need of compassionate treatment and a strong dose of reality, into a civil right in need of defending.
Dr. McHugh’s closing statement is telling. He states, “Gird your loins if you would confront this matter. Hell hath no fury like a vested interest masquerading as a moral principle.”