Mobeen Vaid (MA Islamic Studies, Hartford Seminary) est un intellectuel et écrivain public musulman (voir ici et ici) qui se concentre sur la façon dont les cadres de pensée islamiques traditionnels se croisent avec le monde moderne. Il est l'auteur d'un certain nombre d'articles sur les normes sexuelles et de genre islamiques, notamment «L'islam peut-il accommoder les actes homosexuels? Le révisionnisme coranique et le cas de Scott Kugle »(MuslimMatters, 2017).
Waheed Jensen est médecin, chercheur médical, blogueur, et producteur et animateur de «A Way Beyond the Rainbow», une série de podcasts dédiée aux musulmans éprouvant des attirances envers le même sexe qui veulent vivre une vie fidèle à Allah et à l'Islam et aider les familles musulmanes , les communautés et les institutions abordent les questions liées à l'islam et à l'homosexualité dans le monde contemporain.
Les auteurs tiennent à remercier en particulier le Dr Hatem El-Haj et Sh. Mustafa Umar pour leur examen généreux et attentif de ce document, en particulier la section IV, «Islam et transgenre». Puisse Allah les récompenser ainsi que les autres savants qui ont pris le temps de lire cet article et de fournir des commentaires pour aider à contrôler, façonner et interpréter le matériel.
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N.B.: Les éléments soulignés en orange sont des hyperliens pour faciliter la navigation vers les sources originales. Pour une lecture plus facile, vous pouvez télécharger un PDF de cette étude au format article (avec notes de bas de page) en cliquant sur ici.
Tandis que partie 1 de cette étude1 a étudié la tradition islamique et établi la position normative de l’islam sunnite sur la non-conformité de genre, nous passons maintenant à un examen des identités de genre dans la société contemporaine. Le monde moderne a donné naissance à une myriade d'identités de genre alternatives qui sont considérées comme défavorisées par rapport à ce que l'on considère comme les privilèges dont jouissent les individus «cisgenres» – un terme désignant ceux dont le sexe biologique correspond à leur sexe psychologiquement intériorisé. Bien qu'il existe diverses listes en ligne énumérant ces nombreuses catégories de genre et identités sexuelles alternatives, l'expansion rapide de la sexualité en tant qu'ensemble indépendant de constructions conceptuelles rend difficile le suivi du rythme. En discutant de cette extension, David Frank et Nolan Phillips écrivent:
L'expansion de la sexualité dans la société se renforce d'elle-même. La légitimation de chaque nouvelle identité en engendre d'autres. Ainsi, l'ancien centre gay du campus se transforme en le centre lesbien et gay, puis le centre LGB, puis le centre LGBT, puis le centre LGBTQ, et à un moment donné le centre LGBTQI, et maintenant même le centre LGBTQQIAAP (lesbienne , gay, bisexuel, transgenre, queer, interrogateur, intersexuel, asexué, alliés et pansexuel).2
Ces initialismes élargis conglomérent deux catégories: l'orientation sexuelle (gay, lesbienne, bisexuelle, etc.) et les identités de genre (transgenre, non binaire, etc.). Cette conglomération est, entre autres, stratégique.3 Les genres et sexualités alternatifs sont considérés comme marginalisés et se situant en dehors du binaire masculin-féminin dominant. Les identités de genre alternatives et les orientations sexuelles alternatives sont sujettes à l'opprobre moral de la religion traditionnelle, une institution – ou, plutôt, un ensemble d'institutions – considérée comme un obstacle important, sinon le plus grand, à la réalisation complète sociale, culturelle et politique. égalité. Les défenseurs des deux sont également intéressés à faire progresser les droits de ceux qui sont assis dans les crevasses interstitielles occupées par les communautés minoritaires. Ce faisant, les partisans LGBT + cherchent à défaire ce qu'ils identifient comme des paradigmes enracinés de préjugés qui restent comme les vestiges d'une ère prétendument révolue de religion réifiée, «médiévale» et de ses canons concomitants qui continuent à empiéter sur les libertés sociales et politiques du monde moderne. individuel. Cela inclut, mais sans s'y limiter, l'utilisation d'un langage sexué, la notion «traditionnelle» de mariage et les normes sociales qui stigmatisent les choix liés au sexe des particuliers. Tout cela, et bien plus, est considéré comme devant être démantelé.
Cette étude commence par fournir un compte rendu détaillé de ce phénomène, puis passe à examiner le genre sous un angle conceptuel tout en se livrant à plusieurs débats qui ont émergé au cours de la dernière décennie liés à la non-conformité de genre. Suite à cela, nous portons notre attention sur le transgenre en tant que phénomène moderne, en commençant par une brève histoire, puis en examinant les nombreuses questions qui le croisent, y compris, mais sans s'y limiter, les débats dans le domaine de la psychologie, de la jeunesse transgenre et de la médicalisation des adolescents. qui souffrent de dysphorie de genre et de défense des transgenres en tant que programme politique et culturel distinct. Enfin, nous concluons avec une section passant en revue les décisions juridiques (fatāwā, chante. fatwā) par des universitaires musulmans sur la non-conformité de genre et les opérations de changement de sexe.
A. Le genre: une construction sociale?
Une caractéristique commune du discours contemporain est son appel constant aux débats sur le genre et le genre. Les musulmans et les non-musulmans sont plongés dans les questions de rémunération équitable, d'inégalité entre les sexes perçue (et réelle), et constitue un «rôle» de genre (en supposant qu'il existe une telle chose). Malgré ce débat soutenu et souvent déchaîné, la conception centrale de ce qui comprend en fait le genre fait rarement l’objet d’un examen et d’une délimitation minutieuse. La présomption d’une analogie entre le sexe et le sexe biologique est implicite dans de nombreux débats sur le genre, c’est-à-dire la présomption que le sexe reflète la composition psychologique d’une personne de la même manière que le sexe reflète la composition biologique d’une personne. Lorsque vous remplissez un formulaire, on est généralement invité à choisir parmi un binaire de sexe masculin ou féminin (et de plus en plus «autre» ou ayant la préférence de ne pas dire) lors de l’identification de son sexe. Quand on regarde des sports, on se met à l’écoute de l’athlétisme masculin et féminin, et quand l’envie de se soulager se fait sentir, on est dirigé vers les toilettes pour hommes ou pour femmes. De ces manières et plus encore, la téléologie naturelle des hommes et des femmes en tant que genres distincts distingués par leur composition biologique est renforcée.
Les théoriciens modernes du genre mettent en doute cette conception du genre, arguant au contraire que le genre est quelque chose de culturel que l'on devient «par un processus complexe de socialisation».4 Cette conception est étayée par des preuves anthropologiques mettant en lumière diverses cultures et sociétés qui ont formellement reconnu trois genres ou plus,5 parallèlement aux myriades de différences inhérentes aux sociétés qui maintiennent une stricte binaire de genre. Ces différences s'ossifient dans les sociétés via les normes sociales, qui sont communiquées à travers des méthodes de socialisation qui incluent la représentation médiatique, les conventions scolaires et la perpétuation des attentes masculines contre féminines des parents envers leurs enfants à un jeune âge (sélections vestimentaires pour enfants, comment les parents parlent à leurs enfants, nomment les coutumes, etc.). De manière critique, étant donné que chaque société manifeste le genre d'une manière qui lui est largement propre (variante vestimentaire, rôles sociaux, etc.), on fait valoir que «le sexe du corps ne porte aucun nécessaire ou déterministe relation avec la catégorie sociale dans laquelle vit ce corps. »6 En d'autres termes, le genre désigne uniquement l'attente sociale et ne pas la biologie.sept
B. Sexe: déterminé biologiquement
Les critiques qui militent contre ce point de vue mettent en avant la constitution biologique en tant que déterminant substantiel de l'identité de genre. Cette approche soutient que «les caractéristiques biologiques des sexes sont à la base des différences entre les sexes – les chromosomes X et Y et les activités hormonales influencent une gamme de qualités individuelles allant des caractéristiques corporelles à la pensée en passant par la motricité».8 Les partisans du modèle biologique ne réduisent pas le genre à la seule composition matérielle ou biologique, reconnaissant pleinement l'éventail des facteurs environnementaux et sociaux qui peuvent contribuer et contribuent souvent à la canonisation des rôles et des conceptualisations de genre. Cependant, ce que les partisans de l'influence biologique soutiennent, c'est que les catégories de genre, aussi profondément informées par les facteurs sociaux, croisent invariablement les identités de genre traditionnelles hommes-femmes, elles-mêmes déterminées presque universellement sur la base de la distinction anatomique des sexes.
Un enchâssement historique presque universel du genre dichotomisé en homme et femme est difficile à attribuer à des facteurs purement externes comme des conventions sociales variables et contingentes. Même les sociétés qui ont reconnu trois genres (ou plus) l'ont fait d'une manière qui circonscrit nécessairement les conceptions de genre alternatives dans une dichotomie permanente homme-femme (les genres alternatifs représentant des anomalies strictes et non des distributions statistiques de l'identification du genre dans ces sociétés). Ces genres alternatifs se manifestent le plus souvent sous la forme d'hommes efféminés, de femmes masculines ou d'une combinaison de ceux-ci. En d'autres termes, l'assimilation des identités de genre ajoutées a, comme question d'auto-définition, pris comme point de référence principal le binaire normatif existant entre l'homme et la femme.
Il est intéressant de noter que les religieux dévoués n'ont pas été les seuls à affirmer l'inhérence du genre contre les efforts constructivistes; même certaines féministes de premier plan ont contesté l'idée qu'un individu peut vraiment passer d'un sexe à l'autre. Désignées par certains comme des «féministes radicales trans-exclusives» (TERF),9 Les universitaires féministes Germaine Greer, Janice Raymond et d'autres ont contesté les notions de transition entre les sexes. Œuvre de Raymond en 1979 L'empire transsexuel: la fabrication de la She-Male fautes à une société qui a produit des hommes qui «objectivent avec enthousiasme les femmes dans le viol, la pornographie et la« traînée »» pour avoir également donné la vie à des hommes qui, soutenus par la même socialisation habilitante, s'objectivent à travers «l'homme à la femme construite» transitions.dix Ce faisant, le transsexualisme en vient à comprendre «l'ultime, et nous pourrions même dire la conclusion logique de la possession masculine de femmes dans une société patriarcale. Littéralement, les hommes ici possèdent des femmes.11
Comme Raymond, Greer a également placé les discours sur la fluidité des genres dans le paradigme du patriarcat, en considérant le transgenre12 comme une appropriation de la constitutionnalité féminine en réduisant la définition de ce que signifie être une femme d'un sexe (apparenté à l'homme) à un non-sexe.13 En conséquence, pour Greer, les interventions chirurgicales visant à enlever les organes génitaux masculins constituent un type de mutilation et, en fin de compte, ne parviennent pas à atteindre leurs objectifs, car l'ablation des organes génitaux masculins ne modifie pas plus le «fait chromosomique que l'ablation de la queue des chiots (…) produit une race sans queue.14 À l'appui de son argument, Greer rassemble des statistiques alarmantes concernant la vie post-transition des transsexuels, y compris les taux élevés de prostitution, le VIH, les hépatites B et C, la syphilis active et la demande de chirurgies correctives ultérieures pour traiter les tissus nécrosants, les échecs de greffe et la réduction ou des voies vaginales fermées.15 Dans une interview de la BBC en 2015, lorsqu'elle a été invitée à parler de sa position sur le transgenre, Greer a rétorqué que les femmes transgenres ne «ressemblent pas, ne ressemblent pas et ne se comportent pas comme des femmes».16
La célèbre universitaire Camille Paglia, une «féministe dissidente» qui se décrit elle-même, a également critiqué la fluidité des genres. Dans un éditorial de 2014 publié dans Temps magazine, Paglia écrit: «L'idéologie du genre dominant le monde universitaire nie que les différences entre les sexes soient enracinées dans la biologie et les considère plutôt comme des fictions malléables qui peuvent être révisées à volonté.17 Plus récemment, Paglia est restée sincère dans son soutien à une conception biologiquement influencée du genre, déclarant dans une interview de juin 2017:
Il est certainement ironique de voir comment les libéraux qui se postulent en défenseurs de la science en ce qui concerne le réchauffement climatique (un mythe sentimental non étayé par des preuves) fuient toute référence à la biologie en ce qui concerne le genre. La biologie est systématiquement exclue des programmes d’études féminines et d’études de genre depuis près de 50 ans. Ainsi, très peu de professeurs et de théoriciens actuels en études de genre, ici et à l'étranger, sont intellectuellement ou scientifiquement préparés à enseigner leurs matières.
La froide vérité biologique est que les changements de sexe sont impossibles. Chaque cellule du corps humain reste codée avec son sexe de naissance pour la vie. Des ambiguïtés intersexes peuvent survenir, mais ce sont des anomalies du développement qui représentent une infime proportion de toutes les naissances humaines.18
Ces voix féministes ne sont pas les seules à désapprouver le constructionnisme de genre. La neurologue de l'Université York, Debra Soh, a rédigé un éditorial dans le LA Times en 2017, demander si les féministes de genre et les activistes transgenres «sapaient la science» en insistant sur le fait que le genre était simplement quelque chose dans lequel on était socialisé.19 Dans son article, Soh soutient qu'en poursuivant un programme politique particulier, les théoriciens du genre ont abandonné des recherches scientifiquement fondées et étayées à plusieurs reprises qui affirment les différences anatomiques et physiologiques entre les hommes et les femmes. Ces distinctions incluent la structure et la fonction du cerveau (comme la fluidité verbale, le traitement visuospatial, etc.), un domaine dans lequel Soh est un expert. En plus des affirmations de Soh, la recherche médicale abonde en examinant les caractéristiques et les caractéristiques spécifiques au sexe, des études récentes examinant comment «le sexe génétique peut entraîner des différences entre les sexes dans l'étiologie et la progression de la maladie».20
Les arguments enracinés dans la composition intrinsèque et biologique s'étendent parfois au-delà des êtres humains en indiquant la vie animale et les rôles de genre observés dans celle-ci. Andrew Sullivan, ancien chroniqueur pour Magazine de New York qui écrit actuellement en tant qu'indépendant blogueur, a récemment offert un commentaire reflétant ce point précis, à savoir que la distinction homme-femme, bien que détestée par les théoriciens du genre et les féministes modernes, est la norme de facto dans la nature. Sullivan écrit que bien que les progressistes protestent contre l'idée que le genre correspond au sexe biologique, ils «ne font pas actuellement campagne pour fermer la planète Terre. car elle révèle que dans presque toutes les espèces, mâles et femelles se comportent différemment – très différemment – et il ne semble pas y avoir de «patriarcat» en place pour y parvenir. » Sullivan poursuit en disant qu '«il est d'une évidence frappante que pour les progressistes d'aujourd'hui, les humains sont la seule espèce sur cette planète où la différenciation des sexes n'a pas de base claire dans la nature, la science, l'évolution ou la biologie. C'est là qu'ils sont aussi hostiles à Darwin que n'importe quel créationniste.21
Il y a eu des efforts récemment pour problématiser ce qui est perçu comme une exclusion du transgenre du domaine de la justification biologique. Certains ont affirmé l'existence de variations dans le comportement sexué parmi la vie animale, y compris certaines espèces qui présentent un déguisement de genre. Un article récent de Juliet Lamb intitulé de manière provocante «Y a-t-il des penchants« transgenres »chez les animaux?» était l'un de ces efforts, bien qu'il admette dans sa conclusion la nature plutôt tendancieuse de l'analogie entre les «ruses de déguisement de genre d'animaux non humains et l'identité de genre humaine».22 Des efforts plus sérieux ont émergé qui ont mis en avant la structure du cerveau comme le facteur biologique crucial causant une dysphorie de genre interne et dispositionnelle. Nous examinons ces arguments dans la section suivante.
Recherche sur la structure cérébrale et transgenre
Tout comme dans le cas de l'homosexualité, des efforts récents ont été faits pour impliquer les facteurs biologiques comme cause du transgenre. Contrairement à l'homosexualité, cependant, l'affirmation d'une prédisposition biologique au transgenre n'a pas été principalement ancrée dans les appels à des preuves génétiques ou la recherche d'un «gène trans». Bien que des études aient été menées pour examiner les origines génétiques possibles du transgenre, le nombre d'études a été rare, du moins par rapport aux études explorant les facteurs génétiques susceptibles d'influencer l'orientation sexuelle. De plus, ces études se sont largement concentrées sur les sujets MtF (homme-femme) étant donné la fréquence du transgenre MtF par rapport à leurs homologues FtM (femme-homme).23 De plus, les résultats ont été en grande partie non exceptionnels ou non concluants en raison de divers facteurs, y compris un manque de taille des échantillons, des complications introduites par des sujets recevant un traitement hormonal et des différences qualitatives entre les transsexuels qui s'identifient comme homosexuels par rapport à leur naissance (c.-à-d. Biologique). le sexe et ceux dont les attraits sont hétérosexuels par rapport à leur sexe natal.
Une étude qui est parfois citée à l'appui d'une influence génétique sur le transgenre a été menée par un groupe de chercheurs australiens en 2008. Diffusion provocante par les médias de l'époque avec des titres comme «Transsexual Gene Link Identified».24 et «Une étude transsexuelle révèle un lien génétique»,25 les conclusions réelles de l'étude étaient beaucoup plus modestes. Entrepris dans le but d'inspecter les causes génétiques possibles du transsexualisme, l'étude a examiné «le rôle des polymorphismes de longueur de répétition associés à la maladie dans les gènes des récepteurs aux androgènes (AR), des récepteurs des œstrogènes β (ERβ) et de l'aromatase (CYP19).»26 Ces trois variantes de gènes sont généralement associées à la sous-masculinité et / ou à la féminisation, et l'étude n'a trouvé aucune association pour le transsexualisme (un terme utilisé dans des études antérieures de manière interchangeable avec le transgenre) pour l'ERβ ou le CYP19 les gènes. Une association a été identifiée pour le gène AR, avec la conclusion que «l'identité de genre masculine pourrait être partiellement médiée par le récepteur des androgènes »(italiques ajoutés).27 Ainsi, les allégations de disposition génétique restent sans fondement, et les efforts pour identifier les fondements génétiques du transgenre sont réexaminés, avec une nouvelle étude en cours examinant un génome transsexuel comme cause possible.28
Bien que les études examinant les facteurs génétiques du transgenre aient été soit peu concluantes, soit soutiennent la conclusion selon laquelle les identités de genre discordantes n'ont pas de base génétique, la recherche neurologique a livré des conclusions ostensiblement plus fiables pour ceux qui plaident en faveur d'une origine biologique de la dysphorie de genre. En conséquence, la notion de «cerveau trans», ou incongruités de genre dans le cerveau, a été avancée comme la principale source de dysphorie de genre dans les discussions transgenres contemporaines. En abordant cette affirmation, il est important d'abord de reconnaître et de reconnaître pleinement la nature de la malléabilité neurologique telle que représentée dans le concept de neuroplasticité. La neuroplasticité fonctionne souvent aujourd'hui comme un mot à la mode utilisé pour suggérer que l'on peut recâbler presque entièrement son cerveau (et, parfois, de manière assez fantastique). Le neurobiologiste moléculaire et développemental Moheb Costandi écrit que parmi le grand public, la neuroplasticité «est généralement mal comprise, et les idées fausses sur ce qu'est la neuroplasticité et ce dont elle est capable sont monnaie courante».29 Costandi poursuit en décrivant la neuroplasticité comme «un terme fourre-tout faisant référence aux nombreuses façons différentes dont le système nerveux peut changer».30 Bien qu'il y a seulement cinquante ans, le consensus scientifique n'ait reconnu qu'une notion limitée de la formation du cerveau qui s'est finalement calcifiée avec le temps, la recherche au début des années 1960 a commencé ce qui allait devenir une refonte de cette orthodoxie antérieure, démontrant dans une variété d'expériences la malléabilité complète du cerveau. fonction et l'effet de l'apprentissage et d'autres expériences sur le matériel cérébral. A titre d'exemple, une étude menée sur des chauffeurs de taxi à Londres a révélé qu'ils avaient un volume de matière grise plus important dans l'hippocampe, résultant de l'acquisition de connaissances spatiales.31 De plus, le même Une étude a révélé que plus les chauffeurs de taxi restaient longtemps dans leur profession, plus leur volume d'hippocampe postérieur droit augmentait.32 Pour mettre cet exemple en termes simples, les composantes de la structure cérébrale des chauffeurs de taxi s’adaptent au fil du temps au type de connaissances et d’expériences que les chauffeurs ont maintes fois réalisées au cours de leur vocation quotidienne. D'autres études se sont concentrées sur l'impact de la conception de soi et des facteurs psychologiques sur le cerveau, comme la méditation,33 stress,34 et intentionnalité.35
Compte tenu de l'ampleur de la malléabilité neurologique, il va de soi que les personnes qui se conçoivent comme dysphoriques de genre pendant de longues périodes de temps en viendraient à acquérir des particularités neurologiques reflétant cette conception de soi. C'est encore plus le cas pour ceux qui se sont convaincus depuis des années, voire des décennies, qu'ils possèdent un phénotype désorienté et qui ont reçu une hormonothérapie et / ou ont subi des interventions chirurgicales d'accompagnement à titre «correctif». (Voir Annexe A pour une discussion plus complète de l'interaction entre le cerveau et la culture à la lumière d'une théorie émergente de la morphologie du cerveau appelée le modèle culture-cerveau-comportement.)
Néanmoins, l'article le plus fiable résumant les études antérieures sur la structure cérébrale et le transsexualisme est l'étude de 2016 «A Review of the Status of Brain Structure Research in Transsexualism» de Guillamon et al.36 En ce qui concerne la voie développementale du transsexualisme, il existe trois grandes trajectoires qui servent de lentille paradigmatique à travers laquelle les études sur la dysphorie de genre (GD) sont menées: début précoce, tardif et rapide. (Nous reviendrons sur cette trifurcation plus loin dans la section intitulée «Transgenre» ci-dessous.) Correspondant à ces trajectoires sont des attractions sexuelles distinctes: la dysphorie de genre précoce (débutant dans l'enfance et se poursuivant jusqu'à l'adolescence et à l'âge adulte) correspond presque toujours à des attirances homosexuelles ( MtF androphilia et FtM gynephilia), tandis que la dysphorie de genre tardive survient plus facilement chez les personnes hétérosexuelles (gynephiles MtF et androphiles FtM).37 L'étude de 2016 discutée ici se concentre exclusivement sur la dysphorie de genre homosexuelle précoce, en se concentrant sur des études qui examinent le phénotype cérébral des sujets FtM et MtF précoces à la fois avant et après le traitement aux hormones sexuelles croisées. Les conclusions pertinentes sont les suivantes:
- Les études examinant les transsexuels homosexuels MtF avant la thérapie hormonale indiquent que «les principaux paramètres morphologiques du cerveau sont en accord avec leur sexe natal chez les MTF homosexuels non traités.38 Ainsi, dans la mesure où le principal les paramètres morphologiques du cerveau sont concernés, les transsexuels androphiles MtF démontrent une congruence avec les mâles cisgenres. Néanmoins, «certaines régions corticales présentent un volume et une épaisseur féminins», bien que ce modèle cortical ne soit «pas le même que celui montré par les femelles témoins».39 De même, les principaux fascicules de matière blanche indiquent une démasculinisation, tandis que les autres fascicules sont masculins. À cet égard, le phénotype cérébral des MtF homosexuelles démontre un caractère distinctif à la fois dans la matière blanche et grise qui affecte principalement l'hémisphère droit du cerveau.
- Les transsexuels homosexuels FtM, comme leurs homologues MtF, présentent des schémas morphologiques grossiers qui correspondent à leur sexe natal. Cependant, comme les transsexuels homosexuels MtF, les transsexuels homosexuels FtM démontrent leur propre phénotype dans d'autres aspects du phénotype cérébral comme l'épaisseur corticale, les structures sous-corticales, etc., et «ces changements sont principalement observés dans l'hémisphère droit.»40
Ces résultats démontrent que ni les personnes homosexuelles MTF ni les personnes homosexuelles FtM ne possèdent un cerveau pleinement «féminisé» (dans le cas des MTF) ou «masculinisé» (dans le cas des FtM) d'une manière qui s'écarte substantiellement de leur sexe natal. Au lieu de cela, le cerveau homosexuel MtF «présente un mélange de traits masculins, féminins et démasculinisés», tandis que le cerveau homosexuel FtM «présente un mélange de traits morphologiques féminins, déféminisés et masculinisés».41 La signification des discordances cérébrales de l'hémisphère droit reste sujette à une étude plus approfondie. L'étude de 2016 note que l'hémisphère droit est «principalement impliqué dans l'analyse de la perception corporelle et de ses connotations émotionnelles» et ajoute que «l'émergence d'une identité masculine ou féminine doit être fortement médiée par le développement précoce d'un homme ou perception de soi du corps féminin. »42 Outre ces conclusions, l'étude de 2016 examine également une étude sur des personnes non homosexuelles MtF, bien que cette étude ait été limitée dans sa taille d'échantillon et n'a conclu à aucune variance significative du phénotype cérébral des hommes témoins.
L'étude de 2016 a également examiné l'introduction du traitement hormonal, et pour les transsexuels MtF et FtM, des changements morphologiques ont été observés après quatre mois de traitement continu, bien que, comme le note l'étude,
des changements sont à prévoir lorsque les hormones atteignent le cerveau à des doses pharmacologiques. Par conséquent, on ne peut pas considérer les schémas cérébraux transsexuels traités aux hormones comme la preuve d'un phénotype cérébral transsexuel parce que le traitement modifie la morphologie cérébrale et obscurcit le schéma cérébral avant le traitement.43
Il convient de noter que les études examinant le comportement et la structure cérébrale de MtF sont plus nombreuses que les études FtM en raison de la fréquence, les cas de transgenre MtF dépassant ceux du transgenre FtM.44
En dehors de l'étude de 2016, une étude tout aussi importante de 1995 intitulée «Une différence de sexe dans le cerveau humain et sa relation avec la transsexualité» est fortement citée à l'appui de l'allégation du «cerveau trans».45 L'étude de 1995 a examiné le cerveau de six transsexuels MTF adultes décédés qui avaient subi à la fois une hormonothérapie et un changement de sexe, constatant que «le volume de la subdivision centrale du noyau du lit de la strie terminale (BSTc), une zone cérébrale essentielle pour comportement sexuel », correspond à la taille féminine.46 Bien que cette étude reste un point de référence commun, des études ultérieures ont compliqué ce tableau, sinon l'ont rendu totalement hors de propos. Anne Lawrence examine l'étude de 1995 aux côtés de deux études ultérieures, une en 2002 qui a observé le développement de BSTc ne se produisant pas avant l'âge adulte et une étude de 2006 examinant l'effet de l'hormonothérapie sur le volume cérébral. En résumant ces résultats, elle écrit:
La théorie du sexe-cerveau du transsexualisme n'a jamais été facile à concilier avec la réalité clinique: le transsexualisme homosexuel et non homosexuel MtF est si différent cliniquement qu'il est presque impossible d'imaginer qu'ils pourraient avoir la même étiologie. Néanmoins, pendant un certain temps, les données de Zhou / Kruijver ont donné à la théorie cerveau-sexe une certaine plausibilité superficielle. En 2002, Chung et al. ont rapporté de nouvelles données qui ont soulevé de sérieux doutes sur la théorie du sexe cerveau-sexe, mais les auteurs capable d'expliquer pourquoi la théorie pourrait encore être plausible. Les nouvelles données rapportées par Hulshoff Pol et al. en 2006 n'a pas infirmé ces explications, mais les a rendues largement hors de propos. L'explication la plus simple et la plus plausible des résultats de Zhou / Kruijver est qu'ils sont attribuables, complètement ou principalement, aux effets de l'hormonothérapie sexuelle croisée administrée à l'âge adulte. Il n'y a plus aucune raison de postuler quelque chose de plus compliqué.
La théorie cerveau-sexe n'a jamais été utile pour expliquer les observations cliniques; maintenant, il est devenu inutile pour expliquer les observations neuroanatomiques. Il est temps d'abandonner la théorie cerveau-sexe du transsexualisme et d'adopter une théorie plus plausible et cliniquement pertinente à sa place.47
Étant donné l'intersection entre les phénotypes cérébraux sexuellement divergents et l'homosexualité chez les transsexuels, le sexologue américano-canadien Ray Blanchard a émis l'hypothèse que «la transsexualité homosexuelle MtF et FtM est une expression extrême de l'homosexualité», suggérant «le continuum suivant: homosexuel → homosexuel dysphorique homosexuel → homosexuel transsexuel . »48 Blanchard a poursuivi en théorisant la transsexualité non homosexuelle MtF comme une paraphilie distincte qu'il a inventée autogynéphilie, un terme grec signifiant «l'amour de soi en tant que femme».49 La théorie de l'autogynéphilie s'est développée en réponse à des recherches et des études répétées dans lesquelles des patients biologiquement non homosexuels de sexe masculin ont massivement rapporté un désir érotique d'incarner le sexe féminin comme principale motivation pour adopter un comportement transgenre et suivre un traitement médical transgenre.50 Blanchard n'est pas seul dans ce constat, des études rapportant ce phénomène dès le début du XXe siècle.51 D'autres études ont plaidé en faveur d'une correspondance entre le désir d'amputation d'un membre et le transsexualisme non homosexuel MtF en raison du chevauchement du désir de «corriger» son phénotype pour correspondre à son identité perçue.52 Les parallèles entre les deux phénomènes incluent «un profond mécontentement à l'égard de l'incarnation, des paraphilies apparentées dont les conditions dérivent plausiblement (apotemnophilie – un désir aigu d'amputation d'un membre – et autogynéphilie), l'excitation sexuelle à partir de la simulation du statut recherché (faire semblant d'être travesti), l'attirance pour les personnes ayant le même type de corps que l'on veut acquérir et une prévalence élevée d'autres intérêts paraphiliques.53
À l'instar de Blanchard, d'autres spécialistes dans le domaine des études de genre et de la psychothérapie, comme Anne Lawrence, Michael Bailey et Kenneth Zucker, ont également approuvé l'autogynéphilie ainsi que les paramètres de base de la conclusion de Blanchard selon laquelle le transsexualisme MtF est une manifestation essentiellement érotique et ne pas indicative d'une essence féminine profondément ancrée. À ce sujet, Bailey écrit dans son travail L'homme qui voulait être reine:
On ne peut pas comprendre le transsexualisme sans étudier la sexualité des transsexuels. Les transsexuels mènent une vie sexuelle remarquable. Ceux qui aiment les hommes deviennent des femmes pour les attirer. Ceux qui aiment les femmes deviennent les femmes qu'ils aiment.54
Plusieurs écrits ont été publiés critiquant les conclusions de Blanchard, notamment une étude de Charles Moser, qui plaide contre l’autogynéphilie en tant qu’explication complète de la transsexualité gynephile MtF.55 Au lieu de cela, Moser suggère une multiplicité de causes qui nécessitent un diagnostic clinique indépendant sans approuver aucun facteur en particulier comme étant complètement en corrélation avec la transsexualité MtF non homosexuelle.56 Le débat reste actif, Anne Lawrence rédigeant un article de commentaire sur la critique de l’autogynéphilie par Moser.57 Dans cet article, Lawrence remet en question la rigueur de la recherche de Moser, mettant en évidence les lacunes de ses méthodes de recherche.58
En plus de cela, des questions plus fondamentales entre la relation entre la morphologie cérébrale et la cognition restent sujettes à d'importantes controverses scientifiques. Perhaps the fiercest critic of those who instrumentalize neurological research and brain imaging to explain cognitive processes was the late William Uttal. Drawing on the works of philosophers, neuroscientists, and others, Uttal revealed problems at the core of cognitive neuroscience, including the “enormous complexity, non-linearity, and complex interaction of both the neural and cognitive domains” and how they “pose what may be intractable problems of analysis and explanation for anyone with the temerity to study human mentation.”59 Uttal would go further, describing localization in cognitive neuroscience—attempts to correlate psychological phenomena, be they subjective experiences (i.e., qualia) or mental processes of other sorts, with localized patterns identified in brain imaging—as a “new phrenology.”60 According to this critique, cognitive neuroscience relies on correlative fallacies of the highest order, ones that depend on ill-defined mental activity (the full accessibility of which is itself highly contested), the assumption that psychological phenomena can be reduced to “neural, cognitive, or computational components,”61 and the total lack of ability directly and persistently to correlate parts of the brain with specific tasks (i.e., the problem of replicability).
The application of this critique to brain studies on transgenderism introduces important questions: Can “male” and “female” brains be distinguished so conclusively that aberrant brain features may be regarded as either effeminate or mannish? For instance, if the hippocampi size is enlarged in a female who prefers to dress like a male, does this fall outside the normal range of acceptable hippocampi size observed in women who conform to female sartorial habits? How decisive is this brain difference, and is it different enough to suggest definitively that the brain of this woman is “male”? And what of those whose brain structure and morphology show no changes at all, even after hormone therapy? To what degree should we adopt biological determinism of this sort to explain transgenderism as a phenomenon when its substantive claims are all psychological at their core? And to what degree should we entertain the now common two-step of insisting that individual “choices” be respected regardless of their comprehensibility by any scientific measure while simultaneously proclaiming a “born this way” thesis without so much as a single reliable, verified, corroborated, and peer-reviewed piece of research to support this claim?
To summarize, the relevant findings to date find morphological divergence in the brain to be most pronounced among homosexual transsexuals, though even this research concludes that “the main morphological parameters of the brain” for untreated homosexual transsexuals “are congruent with their natal sex.”62 Greater divergence has been reported among transsexuals who have undergone prolonged hormone therapy, which is consistent with findings in other studies of subjects who have received pharmacological doses of hormones that reach the brain. The data to date does not support significant morphological divergences for untreated heterosexual transsexuals, and many studies on transsexualism remain inconclusive owing to limited sample sizes and other control factors. Some researchers (such as Blanchard) have proposed a theory of MtF homosexual transsexualism as an extreme expression of homosexuality and non-homosexual MtF transsexualism as correlative with a pronounced cross-gender fetish (namely, autogynephilia), while others have drawn parallels between non-homosexual MtF transsexualism and male desire to carry out limb amputation.
Alternative theories abound concerning gender dysphoria, and resistance to anything short of full-fledged confirmation of prevailing ideas concerning gender fluidity and an “essential” gender identity that departs from one’s natal sex has led to severe backlash and targeted campaigns calling for career terminations. In 2016, Dr. Kenneth Zucker, a leading researcher in the field of sex transitions, was fired by a Canadian clinic due to pressure by a group of trans activists.63 More recently, journalist Jesse Singal published a piece in the Atlantic entitled “When Children Say They’re Trans” calling for deliberation and prudence prior to concluding that sex change surgery or hormone treatment is the right solution for gender dysphoric children.64 In response, trans activists have targeted Singal viscerally, questioning his motives and castigating him as uninformed, obstinate, and plainly bigoted.65
These pressures notwithstanding, the origins of transgenderism remain contested, while the significance of brain change is itself subject to considerable debate given the state of neurological research and the malleability of brain structures overall. Accordingly, the simplistic notion of transsexualism as involving a “biological male with a female brain” or vice versa does not cohere with actual research findings, and the various studies used to depict transgenderism as a congenital condition can equally be used to problematize the phenomena of gender dysphoria, hormone therapy, and the desire for surgical alteration. The inherent fluidity of biological disposition simply suggests what is already well known: namely, that whatever one thinks of transgenderism, appeals to inherency are a double-edged sword, and the view that “gender” (as opposed to biological sex) is inherently embedded in one’s psychological state is a primarily metaphysical, rather than a scientific or empirical, claim.
A. Transgenderism: A Brief History
The history of modern Western transgenderism is subject to significant debate. Gender theorists maintain that transgenderism predates the modern era and cuts across human civilization. This view treats gender nonconformity as a biologically determined phenomenon that manifests in myriad taxonomies and communities across human history. Accordingly, any “third gender,” past or present, is regarded as reinforcing a larger narrative of transgenderism as being an essential part of the human condition for a minority of people whose gender identity differs from their anatomical sex. (This characterization, however, is rightly contested by many as an anachronistic transposition of modern Western categories onto past peoples and societies that held no notion of a gender identity distinct from biological sex, at least not in the manner in which it exists today.) This history includes recasting eunuchs, transvestites, the belief in gender ambiguous deities, and related phenomena as all supporting an allegedly long and storied history of the transgender experience.
Critics of this reading argue that transgenderism is—like its exponents contend gender itself to be—socially constructed. Scholars like Sheila Jeffreys chronicle this history and date it to a relatively recent past, with the term transgenderism having been coined only in 2005 by cross-dresser Virginia Prince in order to “create a more acceptable face for a practice previously understood as a ‘paraphilia’—a form of sexual fetishism.”66 Prior to Prince, “transsexualism” was the more common term used to describe persons who desired sex modifications, a phenomenon that itself dates only to the mid-twentieth century.67 As we will see in the forthcoming section on psychological developments, the reengineering of terms and concepts for the purpose of destigmatization figures heavily in transgender advocacy.
The first recorded case of surgical intervention for gender dysphoria is that of Lili Elbe (born Einar Magnus Andreas Wegener, d. 1931), a Danish painter who, after marriage, moved to Paris in 1912 and openly identified as a female.68 In the year 1930, Elbe went to Germany for sex reassignment surgery, which was highly experimental at the time. Elbe underwent four separate surgeries over the course of two years, dying shortly thereafter, in September 1931, due to an infection resulting from a labiaplasty.69 Roughly twenty years later, Christine Jorgensen (born George Jorgensen, d. 1989), a military servicemember during the Second World War, traveled to Copenhagen for a sex reassignment surgery.70 Unlike Elbe, Jorgensen additionally received hormone therapy, returning to the United States in 1952 to headline stories reading “Ex-GI Becomes Blonde Beauty.”71 Jorgensen lived a life of celebrity until his passing in 1989. Jorgensen became an advocate of transgenderism upon his return to the US, stating in the year of his death that he had given the sexual revolution a “good kick in the pants.”72
Sex reassignment surgery was not available in the United States until the year 1965, when the Johns Hopkins Hospital became the first institution in the country to offer it.73 The founder and chief publicist for the program was psychologist John Money, a figure who fell into disrepute following his handling of the ignominious David Reimer case (also known as the “Joan/John” case).
John Money was an early advocate of gender constructionism, arguing that gender was something learned rather than inherent. He was featured on television and in several print media during the early years of the Johns Hopkins sex reassignment program. It was on account of this notoriety that Janet and Ron Reimer approached him seeking advice concerning their infant son, Bruce, who had just suffered a botched electrocauterization procedure intended to remediate Bruce’s phimosis.74 The failed procedure left the infant with a penis damaged beyond surgical repair, and his parents were concerned about Bruce’s future happiness and sexual function given his genital abnormality. Money and the Hopkins team persuaded Bruce’s parents that sex reassignment was in the child’s best interests, arguing that while a vaginal pathway could be constructed surgically, a penis could not. Moreover, given Bruce’s young age, he would have experienced limited, if any, socialization that would contribute to any conception of a male gender identity. The fact that Bruce had an identical twin brother (Brian) would also offer a unique opportunity to put Money’s constructivist theory to the test as a control factor against which Bruce’s successful socialization as a female could be reasonably assessed.
The Reimers consented to Money’s counsel, and at the age of twenty-two months, Bruce underwent genital reconstructive surgery and was subsequently named Brenda, after which he grew up with periodic hormone treatment and psychotherapy from Money and his extended team to reinforce his new female gender identity. Bruce would go on to experience severe psychological distress and damage throughout his life, threatening suicide at the age of thirteen if he had to return to see Money once more. Approximately two years after that incident, Bruce’s parents revealed to their son that he had undergone sex reassignment as an infant, after which he chose to retransition to a male identity and adopt the name David. David subsequently revealed the details of his life and treatment with Money in a memoir written by John Colapinto entitled As Nature Made Him: The Boy Who Was Raised as a Girl. Money’s “therapeutic” techniques and procedures bordered on the unspeakable and regularly involved David participating with his twin brother, Brian, in a variety of sexual acts. David went on to commit suicide at the age of thirty-eight, while his brother Brian developed schizophrenia and died of an overdose of antidepressants in his thirties as well.
The significance of the David Reimer case, at least for our purposes, lies in the activities of John Money and his role as a leading exponent of gender constructionism. Money developed a number of concepts that lie at the center of transgender discourse today, including gender identity, the “love map” (a mental map that guides one’s erotic desires), and paraphilia (a term coined by Money to replace “perversions”). It should also be noted that Money introduced the now common term “sexual orientation” in place of “sexual preference” to signify an immutability in relation to homosexual desires. Over the course of his work with Reimer, Money routinely misrepresented David’s female development as “Brenda,” describing it as an ongoing success with only rare (and relatively minor) setbacks. This deliberate falsification demonstrated Money’s intractable commitment to gender constructionism and is redolent of the dogmatism that is characteristic of many present-day gender constructionists.
Johns Hopkins discontinued sex reassignment procedures in 1979, only fifteen years after initiating them. Though Money’s methods and field work with the Reimers came to light long after the cessation of sex reassignment at Hopkins, some scholars have speculated that Money’s scholarly writings on the subjects of child pornography and incest played a larger role in closing the program. In these writings, Money argued for the destigmatization of incest, claiming that erotic love was entirely natural even among close kin. Money’s proposed sexual schema was indeed an abnormal one, and there is reason to believe that the impact of this literature extended to those on the ground who were disquieted by Money’s publications and research; during this same period, Howard Jones, one of the chief surgeons connected with the Hopkins program, left the institution.
Jon Meyer, who ran Johns Hopkins’ Sexual Behaviors Consultation Unit, published an important review of the Hopkins sex reassignment program in a 1982 study entitled “The Theory of Gender Identity Disorders.” In this study, Meyer reflects upon his decade of work with 526 patients “having the most severe disturbances of gender, disturbances reflected in their application for surgical sex reassignment.” Meyer reported a complex set of clinical symptoms in these patients. For those who underwent sex reassignment procedures, long-term follow-up (ten or more years) “suggested that feelings of isolation and emptiness continued,”75 while there remained “a profound sense that, whereas externals had been changed, the patient was not truly male or female, merely a reasonable facsimile.”76 Meyer concluded that transsexual disjunction between self-representation and anatomy was “a defensive, symptomatic condensation77 of remarkable proportions,” further stating that “the destruction of the meaning ordinarily associated with genital anatomy is a violent psychic act, one means by which the superficially absent rage is expressed.”78 In a similar vein, an earlier 1979 piece by Meyer concluded that “sex reassignment surgery confers no objective advantage in terms of social rehabilitation.”79
Another critical figure worth mentioning here briefly is the former chief of psychiatry at Johns Hopkins Hospital, Paul McHugh, who served as a leading voice in the closure of the Hopkins gender identity clinic in 1979. McHugh has written a number of articles as of late defending that decision, arguing that sex reassignment does little more than “cooperate with a mental illness” and that psychiatrists would do better to try to “fix the minds” of those suffering from gender dysphoria and “not their genitalia.”80 Elsewhere, McHugh ruminates on the state of medical practice:
Without any fixed position on what is given in human nature, any manipulation of it can be defended as legitimate. A practice that appears to give people what they want—and what some of them are prepared to clamor for—turns out to be difficult to combat with ordinary professional experience and wisdom. Even controlled trials or careful follow-up studies to ensure that the practice itself is not damaging are often resisted and the results rejected.81
McHugh’s observations and strident opposition to gender constructionism and its concomitant medical campaign have not gone unnoticed. Trans activists and supporters of transgenderism as a condition requiring medical intervention have maligned McHugh’s research and accused him of “distorting science” and “spreading transphobic misinformation”82 while “dangerously undermining the safety, security and well-being of LGBTQ people.”83 Meanwhile, conservative political actors and representatives have leveraged McHugh’s writings in congressional discussions concerning sex reassignment procedures, including a 2016 House hearing on transgender surgeries.84
In October 2016, Johns Hopkins released a letter entitled “Johns Hopkins Medicine’s Commitment to the LGBT Community” in order to assuage public concern over the possible connection between McHugh and the institution. Although McHugh is not mentioned by name, the letter states that
some have questioned our position, both inside and outside the institution, not because of any change in our practice or policy, but because of the varied individual opinions expressed publicly by members of the Johns Hopkins Medicine community. We have taken these concerns seriously. We want to reiterate our institutional support for LGBT individuals and update you on the work we are doing to further that commitment.85
The letter goes on to announce the following:
- “Johns Hopkins Children’s Center physicians helped lead an American Academy of Pediatrics committee that authored the 2013 policy statement that supports access to clinically and culturally competent health care for all LGBT and questioning youth.
- “In field and clinical research, Johns Hopkins University faculty members have advanced understanding of LGBT health and well-being, contributing to the important work of counteracting the negative effects of bias, discrimination and stigma that can hinder LGBT communities from seeking and receiving the best health care.
- “In the past year, two Johns Hopkins Medicine task forces on LGBT health care have been charged with developing new paths for our institutions to further approaches to evidence-based, patient-centered care for LGBT individuals.
- “We have committed to and will soon begin providing gender affirming surgery as another important element of our overall care program, reflecting careful consideration over the past year of best practices and the appropriate provision of care for transgender individuals.”86
Since publishing the letter, so-called gender affirmation surgical services have commenced and are now publicly listed among John Hopkins’ surgical services.87
Johns Hopkins is but a microcosm of what has been occurring in the public square. Though transgenderism and its underlying clinical diagnosis of Gender Identity Disorder were once regarded as a distinct mental illness, the past decade and a half has witnessed a substantial shift in public opinion. Consequently, determining public and private transgender policy, suitable pronouns, the relationship of gender to personal identity, and the appropriateness of surgical intervention for gender dysphoric adolescents and adults have become politically charged topics that are now being litigated through an eclectic mix of policy makers on Capitol Hill, medical professionals of various fields, activists, and other culturally influential voices.
Simultaneous with this debate has been a marked shift in attitudes towards gender, transgenderism, and adolescent gender self-conception. In a recent study published in the journal Pediatrics, approximately three percent of Minnesota teens reported that they did not identify with traditional gender labels (i.e., “boy” or “girl”).88 In another study conducted by UCLA, a full twenty-seven percent (!) of those studied between the ages of twelve and seventeen in California were determined to be “highly gender nonconforming (GNC).”89 Compare this to reported rates of 6.8/100,000 MtF and 2.6/100,000 FtM transgenderism among adults and the disproportion comes into clearer view. We will return to the subject of adolescent GD below (see subsection “Childhood-onset gender dysphoria”).
It should be noted that emerging treatments of gender nonconformity in gender studies are transcending commonplace transgenderism (i.e., transitioning from one gender to another) with new theories and conceptions of nonconformity that attempt to situate individuals fully outside the established male–female binary. One increasingly invoked category that reflects this tendency is known as genderqueer (GQ), a term used to denote a departure from the gender binary without situating individuals within a prefabricated gender/non-gender stereotype. Though it shares conceptual overlap with transgenderism in its repudiation of the notion of an inherent birth gender, the term genderqueer differs from transgenderism in the “persistent unease (of those who identify as genderqueer) with being associated only with the binary gender assigned to them from infancy—apart from that, their expressions, experiences, and preferences vary greatly from individual to individual.”90
Rogers Brubaker furthers this discourse to examine models of transgenderism that go beyond—or, in other instances, that mix—gender deviations, oftentimes as a result of a desire to maintain aspects of one’s “pre-trans” self. In describing this phenomenon, Brubaker writes:
The desire to continue to express aspects of one’s pretransition self has found support from intellectuals and activists who have sought to emancipate the transsexual experience from prevailing forms of medical control and from the need to pass as a ‘natural’ member of the gender of choice, both of which encouraged or even required rigidly stereotypical gendered presentations of self.91
Brubaker goes on to introduce modes of transgenderism dubbed the “trans of between” and “trans of beyond,” the former of which speaks of the “positioning of oneself with reference to the two established categories, without belonging entirely or unambiguously to either one,”92 while the latter involves “positioning oneself in a space that is not defined with reference to established categories.”93
Although some of these theories are receiving significant attention in certain academic quarters, the phenomenon of gender nonconformity continues to emerge most commonly in the form of transgenderism with two relatively stable identities: MtF and FtM. Given the growing appeal of reformative gender projects and the increasing social authority accorded to constructionist voices and programs, the following section examines the different types of transgenderism and provides a brief review of trans activism today.
Transgenderism is not a single, unified phenomenon. Rather, it covers a variety of phenomena that can diverge considerably from one case to the next. Clinically, the condition that is said to cause transgenderism was formerly known as Gender Identity Disorder (GID), a diagnostic label that held until 2013, when the Diagnostic and Statistical Manual of Mental Disorders (DSM) reclassified the condition as Gender Dysphoria (GD).94 The name gender dysphoria served the purpose of destigmatizing transgenderism and shifting the relevant psychological concern to one of distress, anxiety, and related anguish, in contrast to GID, which implies that gender identity divergence is an objective mental illness in and of itself.
Individuals with GD “experience a strong desire to be treated as the other gender (or some alternative gender different from their assigned gender), and/or to be rid of their sex characteristics, and/or the strong conviction of having feelings and reactions typical of the other gender (or some alternative gender).”95 In examining gender dysphoria, psychologists have attempted to classify the phenomenon into at least three different subtypes. (It should be noted that there are other, less common types that have been discussed and written about, though we will not attend to them here for the sake of simplicity.) The classification of GD into subtypes is critical for a number of reasons. For one, classification assists in better understanding the variability in GD cases and gender transitions. This is a marked departure from the current public discourse, in which transgenderism is treated as a single phenomenon with all cases reducible to a simple matter of individual choice. Cases involving transgenderism can differ dramatically from person to person. Consider, for example, the case of Jazz Jennings, a natal male who was “so feminine that she earned a diagnosis of gender identity disorder at the age of four.” By comparison, Chaz Bono, a natal female, publicly identified as lesbian in his (then her) mid-20s and only transitioned nearly two decades later. Caitlyn Jenner, a natal male, had been heterosexually married (i.e., to women) on three separate occasions and has six children from those marriages. Each of these individuals presents substantive differences concerning his/her gender identity and ultimate transition.
The trifurcation of transgenderism that we will examine here intersects four factors, namely, (1) age (child vs. adolescent vs. adult), (2) speed of onset (sudden vs. gradual), (3) sexual attraction (homosexual vs. heterosexual as measured against natal sex), and (4) sexual ratio (frequency of occurrence in natal males versus natal females). The three types of transgenderism are
- childhood-onset gender dysphoria
- autogynephilic gender dysphoria
- rapid-onset gender dysphoria.
Also referred to as early-onset gender dysphoria, childhood-onset gender dysphoria refers to children, as young as age three up through adolescence, who “behave like the other sex in a variety of ways, including preferences of dress and appearance, play style, playmate preferences, and interests and goals.”96 The latest edition of the Diagnostic and Statistical Manual of Mental Disorders, DSM-5, provides the following description for childhood gender dysphoria:
A. A marked incongruence between one’s experienced/
expressed gender and assigned gender, of at least six months’ duration, as manifested by at least six of the following criteria (one of which must be Criterion A1):
- A strong desire to belong to the other gender or an insistence that one is the other gender (or some alternative gender different from one’s assigned gender)
- In boys (assigned gender), a strong preference for cross-dressing or simulating female attire, or in girls (assigned gender), a strong preference for wearing only typically masculine clothing and a strong resistance to wearing typical feminine clothing
- A strong preference for cross-gender roles in make-believe or fantasy play
- A strong preference for the toys, games, or activities stereotypically used or engaged with by the other gender
- A strong preference for playmates of the other gender
- In boys (assigned gender), a strong rejection of typically masculine toys, games, and activities and a strong avoidance of rough-and-tumble play, or in girls (assigned gender), a strong rejection of typically feminine toys, games, and activities
- A strong dislike of one’s sexual anatomy
- A strong desire for the primary and/or secondary sex characteristics that match one’s experienced gender
B. The condition is associated with clinically significant distress or impairment in social, school, or other important areas of functioning.97
Critics have called the above criteria into question, arguing that they rely heavily on sex stereotypes and include characteristics that are commonly observed among otherwise normal and healthy children. UNE New York Times op-ed by a mother named Lisa Selin Davis, published in April 2017, makes this precise point. Entitled “My Daughter Is Not Transgender, She’s a Tomboy,”98 Davis’s piece expresses frustration with others’ calling into question her daughter’s gender identity simply on account of her interests (she enjoys sports), friends (she is friends primarily with boys), and hairstyle (she likes her hair short). She writes: “I want trans kids to feel free and safe enough to be who they are. I also want adults to have a fluid enough idea of gender roles that a 7-year-old girl can dress like ‘a boy’ and not be asked—by people who know her, not strangers—whether she is one.”99
Although statistics are not precise concerning the prevalence of childhood gender dysphoria, recent studies have reported relative stability of childhood GD cases over the past decade, though adolescent cases have experienced a marked increase.100 Possible reasons noted for the increase in adolescent cases include the influence of social media, a preference for being trans over being gay or lesbian, and the social status given in some youth subcultures to transgender individuals.101 In one study, an adolescent girl is reported to have remarked, “If I walk down the street with my girlfriend and I am perceived to be a girl, then people call us all kinds of names, like lezzies or faggots, but if I am perceived to be a guy, then they leave us alone”102—thus resorting to transgenderism as a recourse against hazing or other forms of anti-gay animus.
Causes of childhood GD remain elusive, though “genes, hormonal influences in the womb, and environmental factors are all suspected to be involved.”103 When GD appears in adolescence, which often falls into the two categories discussed below (autogynephilic and rapid-onset), it is reported that “parent–infant interpersonal issues” and related trauma—including, but not limited to, sexual trauma—can play a contributing role,104 as well as depression and anxiety, borderline personality disorder, and social contagion.105
A feature of adolescent GD is the reported correspondence it bears with Autism Spectrum Disorder (ASD). Samples of adolescents who are referred to gender identity services reveal that six to twenty percent of such cases also have ASD, thus representing a significantly higher correlation as compared with studies conducted on adults (though ASD and GD co-occurrence is nonetheless common among adults as well).106
It should be noted here that of all GD types, childhood cases have become a particularly acute battleground in the public square. Much of the consternation surrounds the question of what is known as desistance, which refers to the possibility—and, in most cases, the likelihood—of children eventually going on to accept their biological bodies rather than permanently identifying as transgender. Studies examining adolescent GD have consistently reported statistically high rates of desistance, with some studies revealing a desistance rate as high as eighty-four percent.107 It should be noted that literally dozens of studies report high rates of desistance, even as the statistical outcomes differ.108 In other words, the self-resolution of childhood GD is a common occurrence and one that is in keeping with what is otherwise known about childhood development and the volatility of childhood self-perception.
In responding to the multitudinous studies confirming high rates of desistance, several transgender advocates have published against what they term the “desistance myth.” In January 2016, Brynn Tannehill of the Trans United Fund published an article in HuffPost arguing against desistance, provocatively entitled “The End of the Desistance Myth.” Though the article alleged that studies reporting desistance were built upon “bad statistics, bad science, homophobia and transphobia,”109 it did not produce any substantive evidence to demonstrate this claim. The only meaningful objection seems to be that desistance is closely correlated with the intensity of childhood GD, such that higher-intensity cases are less likely to desist than lower-intensity ones. Though this is no doubt true—and is confirmed in the very studies critiqued by Tannehill—the possibility of desistance remains even in high-intensity cases (albeit with a lower likelihood).
Considerably more contentious with respect to childhood GD is the issue of medical intervention, including the use of puberty blockers and the initiation of hormone therapy as part of treatment programs. In a 2016 paper entitled “To Treat or Not to Treat: Puberty Suppression in Childhood-Onset Gender Dysphoria,” for example, the authors state that the “paucity of published research on the effects of GnRHa (puberty suppressing medication) on health-related outcome measures calls for studies that might help to advance the evidence-based debate on risks and benefits of puberty suppression.”110 However, just two sentences later, the authors conclude that “despite a limited number of studies, the existing literature supports puberty suppression as an early, sufficiently safe, and preventive treatment for gender dysphoria in childhood and adolescence.”111 This conclusion is shared by Diane Ehrensaft, Director of Mental Health at San Francisco’s Child and Adolescent Gender Center. The conclusions of the 2016 study and Ehrensaft’s advocacy stand in direct contradiction to studies that demonstrate that children treated with puberty blockers report higher rates of self-harm and suicidality compared to those not so treated.112 Dr. Michael Biggs of Oxford University has spoken out against a comparable study endorsing the use of puberty suppressants published by England’s National Health Service (NHS) and has stated that “puberty blockers exacerbated gender dysphoria. Yet the study has been used to justify rolling out this drug regime to several hundred children aged under 16.”113 In addition to the complications and side effects of puberty blockers, the popular claim that the effects of hormone therapy are entirely reversible has itself proved tendentious. When asked about this alleged reversibility, Dr. Polly Carmichael, a clinical psychologist who heads a clinic devoted to treating adolescent gender dysphoria, responded saying, “Nothing is completely reversible.”114
More radical transgender advocates today lobby for adolescent independence and affirmative transgender therapy—including medical intervention—for teenagers and youth struggling with GD without even requiring parental consent. Moreover, some have argued for treating individuals who display indicators of GD and transgenderism at very young ages. Diane Ehrensaft, for instance, contends that “children as young as one year of age are capable of announcing they are transgender, even before they can speak,” further suggesting that a one-year-old girl’s stating “I boy” can be construed as a meaningful indication of gender nonconformity.115
Ehrensaft is not alone in her commitment to radically “affirmative” care. Dr. Johanna Olson-Kennedy of Children’s Hospital Los Angeles is a prominent affirmative care physician and has spoken in the past about radical mastectomy outcomes in girls as young as thirteen. Hacsi Horváth from the University of California San Francisco writes about Olson-Kennedy’s push for medicalizing young girls diagnosed with GD as follows:
She (Olson-Kennedy) doubled down on this affront to Hippocrates by suggesting that if teen girls later regretted the loss of their breasts, they could “go and get” new breasts, suggesting that breast implants would make them as good as new. There has been a tremendous surge over the past decade in girls and young women presenting to gender clinics (Zucker 2017, Littman 2018), and Olson-Kennedy says she has personally ushered more than 1100 of them into the medicalized trans lifestyle. In a 2018 paper, she recommends referring girls for this “top surgery” first, and only afterwards prescribing testosterone—thus removing the option for what might have been a little more time to think through this irreversible decision (Olson-Kennedy, 2018).116
For young children who display signs of GD, Ehrensaft and Olson-Kennedy support “social transitioning” rather than medicalization—with social transitioning considered a precursor to eventual medical intervention. Social transitioning, which can be applied to children of any age (including infants), represents a form of transitioning in which parents and others socialize the child into an alternative gender identity (adjusted name, dress, treatment, etc.).117
This fractious climate has made it exceedingly difficult for parents of GD children to distinguish truth from falsehood or fact from ideology, and the proliferation of transgender affirmative guidelines directed towards educators, counselors, medical professionals, parents, and youth has compounded the already substantial difficulties that families experience when facing a GD diagnosis in their child. Children with GD can exhibit significant “impairment in major areas of functioning, such as social relationships, school, or home life,”118 while adolescents with GD report significantly higher rates of suicidality, psychopathology, self-harm, eating pathologies, poor peer relationships, and higher rates of bullying and social isolation, as well as a greater likelihood of partaking in risky sexual behaviors.119 An ideological program zealously devoted to lowering the possibility of desistance and promoting gender transition obfuscates all these inconvenient facts while selectively marshalling evidence that can be used to encourage gender transition and stifling vital debate before it can even take place. The possibility—indeed, the likelihood—that these children can function in a wholesome, healthy way with who they are biologically is increasingly marginalized and cast as harmful to children.
Coined thirty years ago by Ray Blanchard, the term autogynephilia denotes a male (adolescent or adult) who demonstrates a “propensity to be sexually aroused by the thought of himself as a female,” a common symptom in cases of gender identity disorder (GID) and transvestic fetishism. The development of sexual interest during adolescence typically materializes in sexual fantasies or desires directed towards the opposite sex and can involve sexual arousal, desire, and sexual function. The concept of autogynephilia extends this sexual development for non-homosexual males: an autogynephilic male would, in addition to the aforementioned sexual developments, fantasize about embodying women and, in many cases, act out the fetish. That is, he would feel arousal at the thought of dressing like a woman and, at times, possessing female body parts. Ray Blanchard sees this condition as a type of orientation, one that falls along the spectrum of heterosexuality to homosexuality. In this view, autogynephilia is a type of immutable orientation that will continue to some degree as a lifelong condition.
It should be noted here that our understanding of “orientations” is not firmly established in any field of sexuality. That is to say that although in many cases individuals manifest dominant or exclusive sexual desire for a single sex, the causes behind this phenomenon are not well understood. This is as much the case with same-sex desire as it is with less typical sexual desires and fetishes like autogynephilia. In the case of autogynephilia, the available data and sample sizes complicate the picture, as our scope of understanding is fundamentally limited given the rarity of gender dysphoria and sex reassignment—though in recent years the numbers have increased substantially (which risks obscuring the picture even further by confounding organic occurrences of GD with those contributed to by rising socialization factors). Whatever the case may be, it is fair to conclude that autogynephilia is perhaps the most common underlying condition among males who pursue sex reassignment, and reports show that in recent years, seventy-five percent of male-to-female transsexualism cases in Western countries have involved autogynephilic patients.120
Not all of those diagnosed with autogynephilia pursue sex reassignment or express gender dysphoria. In fact, the majority do not, and some with autogynephilia end up marrying and having children. Autogynephilia, like all conditions, exists along a spectrum. Some can suppress the occasional desire to cross-dress, whereas others may engage in infrequent cross-dressing as a sort of release. Other cases include individuals with a higher intensity of fetish. In an article on autogynephilia, Michael Bailey and Ray Blanchard write:
Although many autogynephilic males find discovery of the idea of autogynephilia to be a positive revelation—autogynephilia has been as puzzling to them as it is to you—some others are enraged at the idea. There are two main reasons why some autogynephilic males are in denial. First, they correctly believe that many people find a sexual explanation of gender dysphoria unappealing—discomfort with sexuality is rampant. Second, they find this explanation of their own feelings less satisfying than the standard “woman trapped in man’s body” explanation. This is because autogynephilia is a male trait, and autogynephilia is about wanting to be female.
It is good to be aware of autogynephilia’s controversial status, because transgender activists are often hostile to the idea. You will not learn more about it from the activists. And if your son has frequented internet discussions, he may also resent the idea. We emphasize that autogynephilia is controversial for social reasons, not for scientific ones. No scientific data have seriously challenged it (emphasis added).121
Autogynephilia can present in men with same-sex or opposite-sex desires (though it is more common among non-homosexuals), while other autogynephilic men are bisexual. For men with heterosexual desires, autogynephilic arousal comes from embodying the sexual other. For men with homosexual desires, arousal often involves the idea of being penetrated as a female. Autogynephilia therefore “provides an implicit theory of motivation for the pursuit of sex reassignment by autogynephilic males: It suggests that they seek sex reassignment because they love (i.e., experience attraction, sexual arousal, and comfort from) the prospect of having bodies that resemble women’s bodies and living in the world as women.”122
Charles Moser argues for the possibility of autogynephilia in female subjects as well, that is, women being sexually aroused by their own bodies.123 As a paraphilia, this is certainly not outside the realm of possibility, and both men and women have, at times, reported sexual arousal by seeing themselves nude.
Though the symptoms are understood (albeit controversial), there is no scientific consensus on the cause of either autogynephilia or gender dysphoria. As we have noted, Blanchard, Bailey, Lawrence, and others view autogynephilia as a type of “orientation” akin to other sexual orientations. The late Joseph Nicolosi, however, argued that gender dysphoria is undergirded by a problem of attachment. On this understanding, gender dysphoria emerges in young children who experience trauma and attachment deficiencies at a young age that later materialize at the point of puberty or manifest fully in adulthood. Nicolosi writes:
Experts in the area of childhood gender identity disorder (GID) have found certain patterns in the backgrounds of GID children. A common scenario is an over-involved mother with an intense, yet insecure attachment between mother and child (emphasis original). Mothers of GID children usually report high levels of stress during the child’s earliest years.
We often see severe maternal clinical depression during the critical attachment period (birth to age 3) when the child is individuating as a separate person, and when his gender identity is being formed. The mother’s behavior was often highly volatile during this time, which could have been due to a life crisis (such as a marital disruption), or from a deeper psychological problem in the mother herself, i.e., borderline personality disorder, narcissism, or a hysterical personality type.
When the mother is alternately deeply involved in the boy’s life, and then unexpectedly disengaged, the infant child experiences an attachment loss—what we call “abandonment-annihilation trauma.” Some children’s response is an “imitative identification”—the unconscious idea that “if I devenir Mommy (i.e., become female), then I take Mommy into me and I will never lose her.”
This is the same dynamic that we see in the fetish, where the boy is “taking in a piece of Mommy” (her shoes, her scarf) and developing an intense (and later sexualized) attachment to an object associated with her.124
Nicolosi’s therapeutic program focused more on childhood-onset GD cases. However, his theory of GD would also be applicable to adults who live with lingering and unresolved distresses buried beneath the surface (Nicolosi did not seem to distinguish between adult, adolescent, and childhood cases of GD). Although addressing such pain may not succeed in eliminating dysphoric feelings, such feelings would, nonetheless, hopefully become more manageable, thus providing individuals experiencing gender anxieties a way to cope with their gender nonconforming thoughts while potentially mitigating the intensity and frequency of such feelings.
Unlike autogynephilia, rapid-onset gender dysphoria (ROGD) is a relatively recent category constructed in response to a growing phenomenon of sudden expressions of gender discordance. Typically, this sudden onset of dysphoria has been observed among (predominantly) female adolescents and young adults. The most thorough and comprehensive treatment of this phenomenon comes to us in the form of a recent study by Lisa Littman. Littman, a researcher at Brown University, studied parents of children who had expressed sudden gender dysphoria with no preceding history of gender nonconforming expression. In examining their children’s unexpected experience of gender dysphoria, parents described “a process of immersion in social media,” including, inter alia, “binge-watching YouTube transition videos and excessive use of Tumblr” prior to the child’s expressing feelings of gender dysphoria.125 Critically, Littman’s study describes in detail the power of social influences in stimulating dysphoric attitudes and promoting the idea of gender dysphoria among otherwise non-dysphoric adolescents, teens, and young adults. The stories of rapid-onset GD cases in Littman’s piece include the following:
- A twelve-year-old natal female who was bullied specifically for going through early puberty and the responding parent wrote, “As a result she said she felt fat and hated her breasts.” She learned online that hating your breasts is a sign of being transgender. She edited her diary (by crossing out existing text and writing in new text) to make it appear that she had always felt that she is transgender.
- A fourteen-year-old natal female and three of her natal female friends who were taking group lessons together with a very popular coach. The coach came out as transgender, and within one year, all four students announced they were also transgender.
- A natal female who was traumatized by rape when she was sixteen years old. Before the rape, she was described as a happy girl; after the rape, she became withdrawn and fearful. Several months after the rape, she announced that she was transgender and told her parents that she needed to transition.126
These stories describe traumatic encounters and social events that contributed in some direct fashion to an eventual desire to embrace an alternative gender identity. Littman concludes with a few key hypotheses. One is, as we have noted, that social influences—both in person and online—provoke gender dysphoria. Another important hypothesis is that in certain instances, gender dysphoria serves as a maladaptive coping mechanism, much the same way that eating disorders serve as coping mechanisms following acute anxieties, bouts of depression, and traumatic events. In describing this phenomenon, Bailey and Blanchard write:
The subculture that fosters ROGD appears to share aspects with cults. These aspects include expectation of absolute ideological agreement, use of very specific jargon, thinking of the world as “us” versus “them” (even more than typical adolescents do), and encouragement to cut off ties with family and friends who are not “with the program.” It also has uncanny similarities to a very harmful epidemic that occurred a generation ago: the epidemic of false “recovered memories” of childhood sexual abuse and the associated epidemic of multiple personality disorder.127
Over eighty percent of rapid-onset GD cases involve females, though it is possible, albeit less common, for men to present with sudden GD as well.128 Many of those presenting with rapid-onset GD had previously been diagnosed with at least one mental health disorder, with several cases of self-harm, sex or gender related disturbances, and family stressors (i.e., death of a parent, parental divorce, etc.).129
Littman’s conclusions have not been without controversy. Originally retracted from Brown’s website after publication in August 2018 because of public pressure and outrage from activist corners, Littman’s paper was republished in March 2019 following a secondary review with edits to address concerns raised during the editorial reassessment. Some have characterized Littman’s research and study as “transphobic,” while trans activist and biologist Julia Serano has disputed rapid-onset GD as a category altogether.130
Recently, journalist Abigail Shrier built on Littman’s research, authoring a work dedicated to the growing phenomenon of female transitioning entitled Irreversible Damage: The Transgender Craze Seducing Our Daughters.131 In it, she documents the rising rates of female transitioning, rates that have flipped what was once a predominantly male phenomenon into one that is now majority FtM in composition in a number of countries. Gender clinics in Stockholm, Toronto, and Amsterdam all report that their ratios of gender dysphoria have shifted to majority natal female patients in recent years, while US incidences of gender dysphoria went from being forty-six percent natal female in 2016 to seventy percent just one year later.132 Shrier details features of female transitioners, the vast majority of whom display no dysphoria in childhood, often come from middle- to upper-middle-class backgrounds, and are heavily influenced by their surroundings, especially social media and trans influencers.133 Prominent trans influencers today command large followings while encouraging social transitioning, donning “binders” (used to suppress breast protrusion), depicting testosterone therapy as cathartic, and advocating deceit in the path of the “greater good” of arriving at one’s true, transitioned self. Along the way, young girls are taught that parental resistance is an indication of hatred and lack of affection or love and that the threat of suicide is an important tool to employ and weaponize when dealing with counselors, teachers, parents, and others who offer anything other than full-throated support.
Many young women today suffer anxieties related to their body image and a pathologizing of feminine norms and features. In such a context, self-harm, depression, and low self-esteem abound, and a desire to abandon the burdens of being a woman can be profoundly persuasive. Shrier quotes therapist Sasha Ayad, whose practice focuses on gender questioning teens, as saying, “A common response that I get from female clients is something along the lines: ‘I don’t know exactly that I want to be a guy. I just know I don’t want to be a girl.’ ”134
Among the many troubling practices of gender affirmative therapy is the rush to medical intervention. For children, this begins with puberty suppressants, a step that is itself often preceded by “social transitioning.” Puberty blockers (Gonadotropin Releasing Hormone (GnRH) agonists) are typically administered at the pre- or early pubertal stage (at around nine to thirteen years of age) to suppress puberty as a first step to transitioning to the desired sex. This is followed by cross-sex steroid hormones at fourteen to sixteen years of age.135 The use of puberty suppressants is recommended by many gender-affirming physicians and therapists as a temporary step to allow adolescent children more time fully to come to terms with their gender identity. Dr. Rob Garofalo, director of the Lurie Children’s Hospital’s Gender and Sex Development Program, states that puberty blockers “allow these families the opportunity to hit a pause button, to prevent natal puberty (. . .) until we know that that’s either the right or the wrong direction for their particular child.”136 At times, children exhibiting even mild gender dysphoria or expressing nominal gender confusion are encouraged to take puberty blockers as a stopgap measure to prevent normal pubertal development. Medical monitoring and psychotherapy ensue to explore possibilities of living as the other gender and to verify if transitioning is something the child really wants. Transitioning to the opposite sex through hormones (with or without eventual surgery) is less invasive on a body with stunted puberty caused by puberty blockers as compared to a body that has started to develop, or has fully developed, sex characteristics of the original sex.137 In this manner, gender affirmative therapy and treatment can serve to promote transgenderism as an eventual outcome, even when it is not in the patient’s best interest. Unsurprisingly, a rising number of adults who were pressured into adolescent transitioning are now going public with their stories of trauma, anxiety, and malpractice by medical practitioners and therapists.138
Although hormone therapy as a secondary step following puberty suppression is often presented as only a “possibility,” in most cases it turns out to be an eventuality. Dr. Norman Spack of Boston Children’s Hospital reports having never seen an adolescent decline hormone therapy after GD diagnosis and the use of puberty suppression.139 Hormone therapy involves the administration of testosterone to natal females and estrogen to natal males. With puberty now blocked and the concomitant gender-specific physical traits prevented from manifestation, hormone therapy proceeds to stimulate opposite-sex gender development. For women, this means an increase in facial and body hair, more severe acne, growth in muscle mass, and the cessation of menses. For men, hormone treatment results in reduced facial hair and slowed body hair growth, the development of breasts, and reduction in testicular size and function.140 During their years on puberty blockers, adolescents’ genitals and reproductive tracts remain in a pre- or early pubertal state, and the pubertal growth spurt is suppressed. If followed by cross-sex hormones, the possibility of reproduction is eliminated.141
The final possible step is surgical intervention. Sex reassignment surgery—sometimes referred to as “sex confirmation surgery”—begins, for men, with an orchiectomy, a procedure that involves the removal of the testicles. Surgeons make an incision in the middle of the scrotum, after which they cut the spermatic cord and remove the testicles. This effectively eliminates testosterone production for men and sets the groundwork for a second surgery, which is either a vulvoplasty or a vaginoplasty. A vulvoplasty is a procedure in which a surgeon uses the skin and tissue of the penis to begin fashioning a synthetic vulva, the outside part of the vagina. A vulvoplasty consists of the following steps: the head of the penis is used to construct a clitoris; the skin from the penal canal and scrotum is used to fashion the labia; and, finally, an opening is created for urination (the urethra).142 An alternative to a vulvoplasty is a vaginoplasty, which involves the fashioning of a full vagina from penile skin and tissue. Patients may experience an orgasm through clitoral stimulation following a vulvoplasty, but they will not be able to participate in vaginal intercourse. A vaginoplasty, on the other hand, allows for sexual intercourse and is thus regarded as a more complete and satisfying form of transition for male-to-female GD patients.
In cases of female-to-male transition, medical intervention involves the reduction and reshaping of the breasts and the removal of the uterus and ovaries. The surgical options for FtM transsexuals are generally bifurcated into what are referred to as “top surgeries” (involving the chest) and “bottom surgeries.” Top surgeries involve reducing breast size and contouring the chest to make it appear more masculine. Of the two sets of procedures, top surgeries are far more common owing to the lower cost and relatively higher rate of success. Bottom surgeries are considerably costlier and more complicated and take place over the course of multiple procedures that can span months, if not years. The principal bottom surgery for FtM patients is a phalloplasty, in which a “neophallus,” or artificial penis, is molded using forearm tissue (or other parts of the body) and then surgically attached in a manner that provides for standing urination. Some FtM patients, following a phalloplasty, elect to undergo yet another surgery to install a penile implant that allows for the appearance of an erection through the use either of manual inflation or of non-inflatable rigid models that are manually moved to mimic the appearance of an erection. The complete set of potential bottom surgeries for a female-to-male patient includes
- a hysterectomy (to remove the uterus)
- an oophorectomy (to remove the ovaries)
- a vaginectomy or vaginal mucosal ablation (to remove or partially remove the vagina)
- a phalloplasty (to turn a flap of donor skin into a phallus)
- a scrotectomy (to turn the labia majora into a scrotum, either with or without testicular implants)
- a urethroplasty (to lengthen and connect the urethra inside the new phallus)
- a glansplasty (to sculpt the appearance of a penile head)
- a penile implant to allow for an erection.143
Bottom surgeries are highly volatile and are perhaps the riskiest of the aforementioned surgical options. Phalloplasties, for instance, have been described as “one of the most complex reconstructions that plastic surgeons are called upon to perform”144 and are fraught with risk due to uncertainties surrounding flap survival and common functional failures. Even relatively successful cases cannot guarantee the rigidity required for successful sexual intercourse, leading one set of experts to describe the practice of phalloplasty as assuming “Herculean dimensions.”145
The complications and side effects of the aforementioned treatments are non-trivial and are rarely disclosed in full to parents, adolescents, and adults considering medical intervention.146 Publicly available literature on trans-affirming sites glosses over the possibility of unfavorable consequences or of medical outcomes that introduce pathological changes or previously non-existent ailments. In the interest of disclosing some of these outcomes, we turn our attention to medical complications of transition treatments in the following section.
In general, puberty blockers used on children are medically indicated for the treatment of a condition known as precocious puberty, in which an early secretion of pubertal hormones brings about all the manifestations of puberty at an earlier age than usual. Such puberty blockers aid in delaying puberty until an appropriate age. However, there is no way to infer that such blockers are safe in physiologically normal children who suffer from gender dysphoria.147
In the United States, the use of puberty blockers for the treatment of gender dysphoria has not yet been approved by the FDA (although their use for the treatment of precocious puberty, prostate cancer, and other conditions has been). The use of puberty blockers for GD is considered “off-label,” meaning that physicians are legally permitted to utilisation such treatments on children with GD but are barred from commercialisation them for the treatment of GD due to the lack of FDA approval.148 The use of puberty blockers for the purpose of treating GD has not yet been proved in clinical trials to be safe and effective. There are many claims that the effects of puberty blockers are reversible.149 It is argued that puberty suppression can “give adolescents, together with the attending health professional, more time to explore their gender identity, without the distress of the developing secondary sex characteristics. The precision of the diagnosis may thus be improved.”150
Some questions worth asking are the following: Is it not to be expected that the development of natural sex characteristics would contribute to an organic consolidation of one’s gender identity, as opposed to interfering with one’s exploration of it? Would not interfering with normal pubertal development possibly influence the gender identity of the child by further hindering his or her gender identity development in line with his or her biological sex, as opposed to allowing for a more accurate diagnosis of gender identity? With puberty blockers, the natural sequence of development is already disrupted. With normal puberty, there is a complex relationship between physiological, psychological, and social factors that shape one’s gender identity, particularly when the physical body matures and sexually differentiates. Would such development resume in a normal fashion after puberty blockers are discontinued? And, what are the psychological consequences that arise in children with gender dysphoria whose puberty has been suppressed for some time and who later come to identify with their natal biological sex?
There are virtually no published studies of adolescents who have discontinued use of puberty blockers and then resumed the normal pubertal development process typical for their sex. Most adolescents studied generally go from suppressed puberty to cross-sex hormones later on, bypassing the most essential step of sexual maturation, the maturation of one’s reproductive organs (which, in some cases, may eventually even be removed altogether). Infertility is therefore one of the major side effects of puberty suppression. The absence of a robust public debate and discussion over sterilizing children in the context of “affirmative therapy” programs is striking to say the least. For any other group of children, an intervention bearing the same degree of medical consequence would be discussed extensively and would include ethics review boards and committees alongside substantial policy debates foregrounding the implications for children in school and the like. On this curious, not to mention worrisome, lack of debate, medical anthropologist Sahar Sadjadi writes:
Needless to say, children are not legally capable of consent, and 9–10-year-olds are not capable of understanding all the health consequences of the treatment. Parents are asked to make life decisions on issues as critical as fertility for young children. Can they make an informed decision and evaluate benefits vis-à-vis risks when confronted with such horrendous forecasts for their children?151
We also have no data concerning the development of primary and secondary sex characteristics in adolescents whose puberty has been artificially suppressed before or at the point of puberty. Hence, there is no rigorous scientific data to support the claim that medical intervention of any sort, including puberty suppression, is reversible.
One question that arises from all this is, Do such treatments contribute to the persistence of gender dysphoria in adolescents who might otherwise have resolved their feelings of belonging to the opposite sex? As mentioned earlier, most children who are diagnosed with gender dysphoria eventually grow out of it. The fact that cross-gender identification persists for virtually all those who undergo puberty suppression raises the question whether such treatments may, in fact, actively increase the likelihood of persisting cross-gender identification. In this vein, Michael Cretalla of the American College of Pediatrics writes:
There is an obvious self-fulfilling nature to encouraging a young child with GD to socially impersonate the opposite sex and then instituting pubertal suppression. Purely from a social learning point of view, the repeated behavior of impersonating and being treated as the opposite sex will make identity alignment with the child’s biologic sex less likely. This, together with the suppression of puberty that prevents further endogenous masculinization or feminization of the entire body and brain, causes the child to remain either a gender nonconforming pre-pubertal boy disguised as a pre-pubertal girl, or the reverse. Since their peers develop normally into young men or young women, these children are left psychosocially isolated. They will be less able to identify as being the biological male or female they actually are. A protocol of impersonation and pubertal suppression that sets into motion a single inevitable outcome (transgender identification) that requires lifelong use of toxic synthetic hormones, resulting in infertility, is neither fully reversible nor harmless.152
A 2018 study carried out by Kaiser Permanente Medical Centers in Georgia and California followed up 2,842 transsexual women and 2,118 transsexual men who had received hormonal treatment.153 Authors found a link between cross-sex hormone use in transsexual women and an increase in vascular side effects such as stroke and venous thromboembolism (VTE), that is, the formation of venous blood clots. Results of the study show that rates of VTE in transsexual women were nearly twice as high as those among cisgender men and women, and the rates of stroke and heart attack among transsexual women were eighty to ninety percent higher than those observed in cisgender women but similar to the rates found in cisgender men. The increase in the rates of VTE and stroke was more noticeable several years after the initiation of estrogen therapy. The evidence was insufficient to allow conclusions regarding risk among trans men participants.
Another study154 showed that, after an average of ten years of cross-sex hormone treatment, a substantial number of transsexual women suffered from osteoporosis at the lumbar spine and distal arm, and twelve percent of transsexual women experienced thromboembolic and/or other cardiovascular events during hormone treatment, possibly related to older age, estrogen treatment, and lifestyle factors.
As for hormone-related cancers in transgender individuals, case reports of trans women diagnosed after the initiation of medical or surgical “gender affirmation” include cancers of the breast and prostate, prolactinomas (a type of pituitary gland tumor), and meningiomas (a type of brain tumor). In transsexual men, published case reports describe cancers of the breast, ovaries, cervix, vagina, and uterus.155 These reports remain sparse, and large studies on the proper incidence of such malignancies in these patient populations remain to be carried out.
As for children, those who transition require cross-sex hormones for significantly longer periods of time as compared to adults. Consequently, they may be “more likely to experience physiologically theoretical though rarely observed morbidities in adults.”156 Hence, boys placed on estrogen treatment may be at a higher risk of developing VTE, cardiovascular disease, weight gain, high blood fat levels and blood pressure, decreased glucose tolerance, gallbladder disease, and breast cancer.157 Similarly, girls receiving testosterone may experience a higher risk for elevated blood cholesterol levels, liver damage, increased blood viscosity and red cell count, and an increased risk of sleep apnea, insulin resistance, and diabetes, as well as unknown effects on breast, uterine, and ovarian tissues.158
One of the most robust studies on sex reassignment comes from Sweden, where a nationwide population-based, long-term follow-up study of sex-reassigned transsexual persons was published in 2011.159 The study followed 324 sex-reassigned persons (191 male-to-females and 133 female-to-males) in Sweden between the years 1973 and 2003. This study found that for sex-reassigned transsexual individuals compared to a healthy control population, there are substantially higher rates of overall mortality, death from cardiovascular disease160 and suicide, suicide attempts, and psychiatric hospitalizations. Authors of the paper argue that even though surgery and hormonal therapy may alleviate gender dysphoria, they are apparently not sufficient to remedy the high rates of morbidity and mortality found among transsexual persons.
Mortality from suicide was strikingly high among sex-reassigned persons (19.1 times increased risk), even after adjustment for prior psychiatric morbidity. In line with this reality, sex-reassigned persons were found to be at an increased risk for suicide attempts (4.9 times more likely). In-patient care for psychiatric disorders was significantly more common among sex-reassigned persons than among matched controls, both before and after sex reassignment, and the authors recommend that there is a need to identify and treat co-occurring psychiatric morbidity in transsexual persons not only before but also after sex reassignment.
A 2001 study of 392 MtF and 123 FtM transgender individuals found that sixty-two percent of MtF and fifty-five percent of FtM subjects suffered from depression, while thirty-two percent of each population had attempted suicide.161 Similarly, in 2009, Kuhn et al. found considerably lower general health and general life satisfaction among fifty-two MtF and three FtM transsexuals a full fifteen years after sex reassignment surgery as compared to controls.162
A 2019 longitudinal study from Sweden by Bränström and Pachankis published in the American Journal of Psychiatry followed up 2,679 individuals who received a diagnosis of gender incongruence (that is, transsexualism or gender identity disorder) between 2005 and 2015.163 Compared to the general population, individuals with a gender incongruence diagnosis were around six times more likely to have had a healthcare visit for mood and anxiety disorders, more than three times as likely to have received prescriptions for antidepressants and anti-anxiety medications, and more than six times as likely to have been hospitalized after a suicide attempt. Increased time since last gender reassignment surgery was significantly associated with reduced mental health treatment (adjusted odds ratio = 0.92, 95% CI = 0.87–0.98). This led the authors to conclude that such data lends support to providing gender reassignment surgeries to transgender individuals who seek them.
Subsequent to the study’s publication, however, multiple clinicians wrote letters to the editor of the journal criticizing the authors’ flawed methodology and cherry-picking of data in order to arrive at the desired conclusions. One such letter was authored by Van Mol, Laidlaw, Grossman, and Paul McHugh (whom we have encountered earlier).164 This led the journal to seek statistical consultations, the results of which were presented to the study’s authors, who concurred with many of the points raised. Upon request, a reanalysis was conducted to compare outcomes between individuals diagnosed with gender incongruence who had received gender reassignment surgeries and those diagnosed with gender incongruence who had not. The results demonstrated no advantage of surgery in relation to subsequent mood or anxiety disorder–related health care visits, prescriptions, or hospitalizations following suicide attempts for that cohort. Given that the study used neither a prospective cohort design nor a randomized controlled trial design, the authors themselves deemed their original conclusion—namely, that “the longitudinal association between gender-affirming surgery and lower use of mental health treatment lends support to the decision to provide gender-affirming surgeries to transgender individuals who seek them”—to be too strong. All this led the American Journal of Psychiatry to issue a major correction and the authors of the study to retract their conclusions. In short, the Bränström study reanalysis demonstrated that neither gender-affirming hormone treatment nor gender-affirming surgery reduced the need of transgender-identifying individuals for mental health services.
Cited in the letter by Van Mol et al. was the Swedish study by Dhejne et al., which employed population controls matched by birth year, birth sex, and reassigned sex. A follow-up time beyond ten years revealed that the sex-reassigned group had nineteen times the rate of completed suicides and nearly three times the rate of all-cause mortality and inpatient psychiatric care compared to the general population, as outlined previously.
The foregoing considerations reveal that sex reassignment alone does not provide individuals with a level of mental health similar to that of the general population (as opposed to proving that sex reassignment positively yields an increased risk of suicide or other psychological morbidities). A 2008 study from Minnesota published in the Journal of LGBT Health found that discrimination and social prejudice do not account for the mental health discrepancies between LGBT-identified individuals and the heterosexual population.165 For transgender individuals, there is a link to underlying trauma that may have contributed to their gender dysphoria and/or subsequent adult transgender lifestyle and conditions. The Minnesota study examined the extent to which a recent experience of a major discriminatory event may contribute to poor mental health among LGBT persons. Researchers included 472 individuals who identify as part of the LGBT community; as a control group, they included 7,412 individuals who identify as heterosexual. The study finds that
(c)ompared to heterosexuals, LGBT individuals had poorer mental health, with higher levels of psychological distress, greater likelihood of having a diagnosis of depression or anxiety, greater perceived mental health needs, and greater use of mental health services, as well as more substance use, with higher levels of binge drinking, greater likelihood of being a smoker, and greater number of cigarettes smoked per day. They were more likely to report unmet mental health care needs. LGBT individuals were also more likely to report having experienced a major incident of discrimination over the past year than heterosexual individuals.166
Later in the study, they remark that “statistically adjusting for discrimination did not significantly reduce mental health disparities between heterosexual and LGBT persons.”167 Now, some might object that this study was conducted in the relatively more conservative United States, where a higher amount of discrimination might be thought to occur as compared to other, more liberal Western societies. However, we can also point to two very recent (2017 and 2018) studies from Sweden, a country with an “international reputation for heeding the human rights of non-heterosexual people.”168 Both studies reveal a similar trend. In one study, researchers found a “significantly elevated prevalence of high-risk alcohol use, cannabis use, and daily tobacco smoking among sexual minorities compared to heterosexuals. Further,” the report continues, “these substantial disparities in substance use more often co-occurred with psychological distress among sexual minorities than among heterosexuals.”169 The study also remarks that “the elevated risk of co-occurring psychological distress and substance use was most notable among gay men relative to heterosexual men (adjusted odds ratio (AOR) = 2.65, CI 1.98, 3.55) (i.e., 2.65 times more elevated) and bisexual women relative to heterosexual women (AOR = 3.01, CI 2.43, 3.72) (i.e., three times more elevated).”170 The study concluded that “experiences of discrimination, victimization, and social isolation partially explain the sexual orientation disparity in these co-occurring problems”171—but, significantly, only partially. In the second study, researchers affirm that “psychosocial experiences may be insufficient to explain and understand health inequalities by sexual orientation in a reputedly ‘gay friendly’ setting.”172
As a sociological phenomenon inclusive of significant medical intervention, transgenderism has only a brief history. There is no historical precedent for drastic surgical changes akin to what we are witnessing today and certainly no historical record for hormone therapy being administered except in the most limited cases of medical necessity. Accordingly, the data related to post-operative and post-medicalized outcomes has only recently been subjected to formal study and examination, though even this is limited and there is much left to be done.
One such area has been that of post-transition regret. A number of articles have appeared online detailing the internal anguish of transitioning, the social factors that apply pressure on individuals struggling with gender dysphoria (including online “affirmative” forums), and post-transition remorse, depression, and general feelings of unhappiness. Lily Maynard (a pseudonym) is one such figure who has become prominent in shedding light on the problems of transgender ideology. Although Maynard herself never transitioned, her daughter, Jessie, did at the age of fifteen, only to detransition years later. Maynard writes an account of the transition and subsequent detransition entitled “A Mum’s Voyage through Transtopia.”173 There are a number of important anecdotes in Maynard’s retelling, but one critical one is how her daughter felt submerged in a particular ideological space, encouraged by friends she had made on trans and gender nonconforming forums, and that all these factors served to intensify her feelings of “being a boy” instead of finding peace and comfort in the female body in which she had been born.
A recent site dedicated to trans remorse is entitled “Sex Change Regret.” Run by Walt Heyer (a detransitioned natal male), the site aims to expose readers to the reality of post-transition regret and to provide resources for those who find themselves in the same boat but do not understand how to revert to the person they once were. A review by the University of Birmingham’s Aggressive Research Intelligence Facility (ARIF) of more than “100 international medical studies of post-operative transsexuals” found “no robust scientific evidence that gender reassignment surgery is clinically effective.”174 In addition to the inefficacy of surgical intervention, ARIF also highlighted how post-operative reporting is skewed to suggest beneficial outcomes. One particular domain where this imprecision comes into focus is the dropout rate of those tracked following sex reassignment. For example, in one five-year study, nearly five hundred people dropped out of a study of 727 post-operative transsexuals.175 The growing specter of regret, complications, underlying psychiatric disorders (that are not and cannot be treated by heavy surgical intervention), and more is increasingly becoming a part of the public transgender conversation. In September 2018, Russia Today aired a documentary entitled “I Want My Sex Back: Transgender People Who Regretted Changing Sex.”176 The documentary focuses on the life of Heyer as well as two others who had undergone surgical transition but did not find comfort in the decision or the peace they had been seeking.
Ryan Anderson’s recent work When Harry Became Sally: Responding to the Transgender Moment includes an entire chapter dedicated to telling the story of “detransitioners.”177 Anderson mentions a number of stories in the chapter, including that of Ria Cooper, who underwent a sex change operation at the age of seventeen. At the time, the surgery was a matter of some controversy given Cooper’s age; however, it was reported that he had undergone a “thorough psychological evaluation” as well as counseling, thus reassuring those who were concerned about the appropriateness of such a heavy-handed procedure for someone so young. Within a year of living as a woman, Cooper attempted to commit suicide twice and ultimately detransitioned back to his natal sex.178 Anderson documents a number of other stories, with common themes related to social pressures, the role of online material and interactive forums telling individuals that transitioning is necessary for those who experience gender atypical feelings, and the contribution of mental health practitioners, divers medical personnel (pediatricians, general practice physicians, etc.), and school administrators (such as counselors and the like) in encouraging otherwise unsure individuals that they should consider and pursue gender transition.
However, this is not the whole story, and not all express regret following a transition. Many advocates of transgenderism claim that the process is lifesaving, with many prominent activists including Chaz Bono, Jazz Jennings, and, more recently, Caitlyn Jenner. Though these figures largely make up the face of the trans movement in America, other transitioned individuals write about the importance of transitioning—and, in some cases, the necessity of sex reassignment—to their mental health. One such figure is Claire Renee Kohner, a prominent MtF who has been featured on HuffPost Live and has written about transgenderism and her story for the New York Times, la Advocate, Bustle, and other publications. Kohner’s story is an important one in that it does not whitewash the difficulties of transitioning, which can often involve serious complications. In a response to the question “What are the most serious negative side effects of gender reassignment surgeries?” Kohner narrates:
I nearly died.
I remember sitting in the examination room of my chosen GRS doctor and going through the risks; as he listed off what could go wrong, I was happily daydreaming about my upcoming surgery and willfully nodding my head,
ignoring what he was saying because, “Hey! My doctor is one of the top GRS surgeons in the US, what could possibly go wrong?”
Who knew that I’d eventually be answering this question as what’s considered a “worst case scenario” patient?
Out of respect for everyone involved, names of people and cities will be withheld from this post. I also want to make sure people reading this understand that I have no regrets and what happened to me will probably not happen to you; however, you need to pay attention to what the risks involved are and how you can deal with them should they arise.
My other disclaimer is to those who would use my story as a means to deter anyone of us from seeking and having the surgeries we need in order to stay alive. This is not some cautionary tale but more of a “please know that this is a major surgery and that all surgeries come with a risk” tale.
(. . .)
It was a typical operation that took ten hours in the operating room and a couple more in the recovery room; nothing was out of the ordinary and for all intents and purposes, it was a successful procedure.
By the second day I was eating solid food, by the third I was walking, and by the 12th of October, I was to be released to a hotel near the hospital for another week to keep me near the facility should something go wrong.
I was 600 miles from home, but my wife of 22 years was by my side. I slept most of the days and changed my bandages. Around the 14th of October we were noticing a significant amount of clear liquid draining from one of my sutures; I should also note that every time I took a shower, I would faint.
I was scheduled for a checkup on the 16th of October and was due to go home on the 19th. At my follow-up appointment, the doctor noticed that one of my sutures was opening up, but given its location to the frenulum, this was common.
The 19th of October arrived and with one quick final checkup at the hospital, I could go home. The suture had opened a little bit further by the 19th and I was running a fever when I arrived. There seemed to be a level of concern by the doctor and his staff, and within an hour I was heading back in to the operating room for a quick mend and I was told I would be heading home on Saturday, the 20th of October.
I woke up in the ICU with a temperature of 104 degrees surrounded by a team of doctors. Still Friday the 19th, a pick line was inserted into my jugular vein so they could inject morphine strait into my bloodstream. My consciousness and pain were being regulated until they could figure out what was going on.
I was awakened around 5 p.m. on the 19th and was told they had to go back in to figure out what the next steps were. I signed the release forms, was injected with morphine and woke up hours later with the team from infectious diseases, my doctor, a gastrointestinal specialist and a doctor that specializes in cardiovascular systems present.
My wife was crying and I asked if I was going to die. Every doctor was silent, then I got the “we are doing everything we can” speech. Still, no one knew what was wrong and I’d have to go in for round three. I was given all of my outcome options—none of them good—and was asked if I wanted to see a chaplain. I remember hearing the nurse say, “Can I give her more morphine?” and the doctor replied, “Not till she signs these waivers.”
I woke up Saturday morning and said to my wife, “It’s time for you to go home.” We have three kids and the household was deteriorating by the amount of stress being put on our kids by neither of us being there. Grandma was babysitting and she could no longer deal with what was happening. This meant I’d be alone in the hospital 600 miles from home. DO NOT EVER DO THIS!!
I had three surgeries that Friday and a surgery on Saturday, Sunday, Monday, Tuesday and Wednesday of that week. Yippee! I got to skip a Thursday surgery but was back in on Friday, the 26th.
(. . .)
At the end of the day, I spent a total of seven weeks in the hospital, I walk with a cane, have lost my sense of taste and I’m going through EMDR therapy for the trauma I experienced.179
Another transgender individual who has written about his experience is Todd Whitworth, an FtM who describes his transition and life in the following terms:
I take self-administered testosterone injections intramuscularly every two weeks. I’ve had a full hysterectomy and oophorectomy including removal of the cervix. Additionally, I’ve had a double mastectomy with chest contouring so that my chest has a more masculine appearance. I’ve been happy with the results, and I feel fortunate in that regard.
I do, however, still know that I am not a biological man. I am happy with the fact that I walk through the world being perceived as male. However, biology reminds me every day that I’m not.
I still experience dysphoria with my genitalia. However, I’ve chosen not to have any genital modification because I do not find the options available for a female-to-male transsexual aesthetically o(r) functionally desirable.180
These cases and others support the idea that some form of gender transition can sometimes serve, at a minimum, palliative purposes for those who experience extreme forms of anxiety, depression, and suicidality as a result of gender dysphoria—notwithstanding the heavy risks and ongoing medical and other complications often attendant upon such procedures.
The Islamic conception of gender is predicated on a set of probative passages in the Qurʾān and instructions of the Prophet (ﷺ) explicating commands, prohibitions, rights, and obligations. Most of the time when revelatory texts instruct believers, the address is not gender-specific. The universal application of verses and prophetic commands is expressed by way of the masculine plural (“O you who believe”: yā ayyuhā lladhīna āmanū)—the masculine plural being the conventional way of addressing a group consisting of both men and women, in contrast to the feminine plural, which is exclusive to women. Thus, believing men and women are commanded to exhibit piety, obey God, request forgiveness for sin, and observe ritual prayers and fasting. Likewise, both men and women are told that they originate from a single soul (nafs wāḥida), namely, Adam. From Adam, Ḥawwāʾ was created (specifically from the rib, according to hadith sources), and from them numerous subsequent generations were born.181 Al-Ṭabarī states that this anthropology serves to remind human beings of their common origin such that the rights of each person would be preserved and wrongdoing averted.182
God, however, makes a clear distinction between men and women, and this division is described as a cosmic pairing that reflects His creative will such that not only humans but also creation writ large exist in complementary pairs. In the Qurʾān, God says, “And of all things We created pairs, that perhaps you may be mindful” (Q. al-Dhāriyāt 51:49). Men and women are described elsewhere as dissimilar (Q. Āl ʿImrān 3:36), and God reminds us of His munificence in that He “grants to whom He wills female (children) and grants to whom He wills males” (Q. al-Shūrā 42:49). In Sūrat al-Najm, God says that “He creates the two mates—the male and the female—from a sperm drop when it is emitted” (Q. al-Najm 53:45–46). Al-Jaṣṣāṣ comments on this passage, stating that it “encompasses all, and this indicates that one cannot be devoid of being male or female, and that the hermaphrodite (too) is not devoid of being one of the two, even if his case is indeterminate to us.”183
Occasionally, verses and prophetic statements address either men or women specifically and, in so doing, delineate particular responsibilities or prohibitions that apply exclusively to one sex or the other. A number of these distinctions reflect physiological differences, such as the rulings related to growing a beard, what is forbidden or permitted during menstruation, and what comprises the ʿawra (that part of the body that must remain covered), all of which are necessarily distinguished by gender. Aside from rulings specific to male vs. female physical embodiment, there is the previously exposited discussion of gender nonconformity in Islam in part 1 of this study,184 which centers on the categories of the khunthā (hermaphrodite / intersex individual) and the mukhannath (effeminate male).
Islam’s treatment of gender is principally anchored in biological composition. Men and women simply sont as God made them, with deep biological differences that inform their behavior in social settings. This elemental fact is evidenced in many places, perhaps none clearer than in the discursive surrounding gender determination for the intersex individual (khunthā).185 All scholars have premised the gender determination of the khunthā on genital function, with supplementary consideration given to subsequent physiological development upon puberty. The disjunction between behavior and mannerisms, on the one hand, and otherwise unambiguous biology, on the other, is addressed in legal discussions of the mukhannath (effeminate male) and the mutarajjila (manly female), and although certain contingent dispensations are provided for the dispositionally (khilqī) nonconforming (with an emphasis on the lack of moral culpability for said dispositional traits), behavior does not override biology when it comes to the ascription of gender. The presence of gender clarity for the anatomically unambiguous is, in fact, the Shāfiʿī school’s justification for refusing a dispensation (allowed by the majority of scholars) for the effeminate male (mukhannath) to remain in the company of women, arguing that such a male, though effeminate, nonetheless retains the potential to marry women upon whom he would enter and therefore should not be permitted to remain with women in confines where they do not observe hijab.
Revelation and its concomitant gender-specific ordinances are in keeping with normative behavioral tendencies derivative of biology. Accordingly, instructions for men to take care of women, protect their households, provide maintenance, play a more pronounced role in religious leadership, and related injunctions accentuate qualities that normally emerge inherently within the male, while interdictions against khalwa (seclusion with a member of the opposite sex), physical contact with non-maḥrams (with some disagreement over the shaking of hands), and recommendations to fast mitigate iniquitous and immoral aspirations that arise from the male libido. Likewise those obligations and prohibitions that apply to women. The outcome is the promotion of a life of feminine and masculine virtue, with a great deal of permitted variation to account for individual male and female differences. Far from confining men and women within narrow stereotypes, revelation allows for latitude, presenting as heroes saintly men and women who took on various tasks in the path of God (though these variations are principally bound up in what is normatively feminine or masculine). Men, for instance, more frequently assume positions of political leadership and are judged for discharging their contingent authority either responsibly or recklessly, just as they are often warriors and, on occasion, even obligated to enter into combat (dereliction from which is sinful). God’s prophetic messengers—all male—were commanded to preach in public capacities, often at great personal risk, and the Children of Israel are rebuked in the Qurʾān for their frequent killing of the messengers sent to them by God. Women, on the other hand, are often mentioned in the Qurʾān in capacities that are domestic and familial in nature. Some receive glad tidings of children miraculously conceived (e.g., Sarah, Mary), whereas others are mentioned for their relationship to their husbands (e.g., Āsiya, the wife of Pharaoh).
Islam’s confirmation and accentuation of gender differences raises the question of how it judges those situations involving gender dysphoria. As we have noted above, individuals with GD not only experience psychosocial alienation because their anatomy conflicts with their impulses, desires, and deep-seated inclinations, but they may also, in fact, construe themselves as being the opposite gender. In some senses, the Sharīʿa offers considerably more latitude than what is normal in modern society, at least insofar as contemporary Western norms create conditions that foment alienation through a limited and parochial notion of masculinity and femininity. Conventional cultural norms surrounding masculinity, for instance, are often associated with forms of “macho” behavior, with caricatured representations of well-sculpted men who engage in sexual dalliances with attractive women and fight recklessly in high-stakes combat scenarios (e.g., James Bond, Rambo, the Terminator). Men who do not subscribe to these representations or who shun such interests in favor of preoccupations that are, say, artistic in nature are often viewed as less manly. But such representations, if held transhistorically, would almost certainly implicate some of the Prophet’s (ﷺ) own Companions. Some, for instance, were regarded for their size and strength, but others were thin and short.186 Some earned valorizations for their efforts on the battlefield, while others were praised as belletrists. Some were eminently wealthy, and others lived as renunciants. Moreover, much of what the Prophet (ﷺ) instructed and practiced himself breaks modern Western stereotypes of masculine behavior, such as the vocalizing of brotherly love, exhibiting platonic affection for members of the same sex such as hugging them or holding them by the hand, and kissing children on the cheek as an act of benevolence and kindness. It remains a common convention in certain Muslim societies today for men to hold hands while walking, a practice that would certainly carry sexual undertones and suspicions of homosexuality in the contemporary West.
Similar variability exists when we observe female Companions. The Prophet’s (ﷺ) wives differed in their demeanor, behavior, and interests. Some inclined towards charity (such as Zaynab), whereas ʿĀʾisha famously transmitted the Prophet’s (ﷺ) teachings after his passing, going on to become one of the chief narrators of hadith. The Sharīʿa’s constraining of gender-specific behaviors is not for the purpose of dictating uniform masculine or feminine archetypes as much as it is for the purpose of imbuing the natural characteristics of men and women with virtue while allowing for the materialization of a spectrum—provided that no cultural or social norm contravenes one’s moral duty (such as a male’s obligation to discharge qiwāma over women in his care, for example). While the Sacred Law accommodates those gender atypical mannerisms (gait, voice, etc.) that come to a person naturally, it prohibits deliberate imitation of the opposite sex in behaviors and affects that go beyond this limit. Such affects may include things like cross-dressing, “social transitioning,” taking on a different name belonging to the opposite sex, men wearing makeup in an unmistakably feminine manner, or women affecting a deliberate and unmistakably masculine experience. At its root, the desire to engage in such behaviors is located in one’s psyche, and the ultimate antidote to this—in tandem with appropriate psychological interventions where needed—is to find comfort and peace in the body in which God has created one, seeing in it perfection, beauty, and an opportunity to attain closeness unto Him.
The first cases we see of scholarly engagement with the prospect of sex reassignment date to the late twentieth century. Ayatollah Khomeini (d. 1409/1989), the Shīʿī jurist and leader of the Iranian Revolution, discussed sex change operations as early as 1967, while Egyptian mufti and Shaykh al-Azhar Jād al-Ḥaqq (d. 1417/1996) wrote a fatwa about them in 1981 in response to a question from the Malaysian Centre for Islamic Research. Khomeini apparently endorsed such surgery within certain parameters.187 Jād al-Ḥaqq responded by sanctioning corrective surgeries to reveal buried or otherwise “hidden” sexual organs, whether male (maghmūra) or female (maṭmūra). He did not, however, sanction sex change surgery, and he explicitly forbade the prospect of men changing into women and vice versa in light of the various hadith that speak of Allah’s curse falling upon “men who take on the semblance of women and women who take on the semblance of men.”188 The issue again rose to prominence in the Muslim world one year later, in 1982, when Sayyid, a male student at al-Azhar University in Cairo, underwent sex change surgery after extended consultations with a psychologist and took on the name Sally. Following the surgery, al-Azhar insisted that “Sally” would neither be allowed to enter the all-female medical school nor be readmitted to the male medical school. “Sally” pursued the matter, which resulted in wide media coverage and, eventually, the involvement of the courts. When Muḥammad Sayyid Ṭanṭāwī (d. 1431/ 2010), who succeeded Jād al-Ḥaqq as Shaykh al-Azhar, was consulted on the matter in 1988, he issued a fatwa—drawing on Jād al-Ḥaqq’s—in which he reiterated the permissibility of surgically repairing hidden male or female sexual organs, stating that “it is obligatory to do so on the grounds that it must be considered a treatment when a trustworthy doctor advises it.” Nevertheless, it has been pointed out that the fatwa was actually non-committal insofar as it “evaded the question of whether the diagnosis of psychological hermaphroditism was acceptable from the point of view of Islamic law.”189 As a result, both sides in the conflict appealed to Ṭanṭāwī’s fatwa in support of their own positions.
In 1989, the Muslim World League’s Fiqh Academy discussed sex change surgery and declared it prohibited except in the case of the anatomically ambiguous intersex person (al-khunthā al-mushkil); as such, the Academy did not endorse the concept of psychological hermaphroditism.190 This has come to be the practically unanimous position among Sunni Muslims.191 A more recent fatwa authored in 2011 by Mufti Zaynul Islām Qāsmī, the vice-mufti of Darul Uloom Deoband, has concurred with this position of Sunni scholarship. In his fatwa, he includes a number of responses to common arguments used by proponents of sex reassignment surgery while taking specific aim at the 2004 ruling of a secular Kuwaiti court permitting such surgery on the basis of necessity (ḍarūra)—a ruling overturned on appeal within the space of a few months.192 Mufti Qāsmī’s responses include the following:
- A reply to those who appeal to the legislative maxim “necessities make the unlawful lawful” (al-ḍarūrāt tubīḥu al-maḥẓūrāt) to argue for the permissibility of transition surgeries. Mufti Qāsmī refutes the applicability of this maxim on the grounds that absolute necessity, in the legally relevant sense, cannot be faithfully or sufficiently proved. This is more so given that the individuals in question have lived, perhaps with some measure of anxiety, for several decades in the body in which they were born. Moreover, the mufti argues that a claim of necessity does not categorically render things permissible in any legal or moral system. If one were to make an exception to permit something impermissible on the basis of inherently subjective internal anxieties that are navigable and manageable, then any number of impermissible desires would have to be accommodated as well, thus opening the door to moral anarchy.193 Here, the mufti glosses Tāj al-Dīn al-Subkī’s qualification of the maxim as requiring existential circumstances that outweigh the sin in question.194 He also appeals to another maxim, namely, that “harm cannot be removed by means of another harm” (al-ḍarar lā yuzālu bi-l-ḍarar). Sex reassignment surgeries, he argues, would violate this maxim in light of the substantial harms inherent in the surgery—a surgery that may or may not succeed in mitigating individual dysphoria but that also introduces any number of complications, impairments, and problems for the individual, both in this life and the next.
- Mufti Qāsmī notes as well that a proper and complete sex change is, in fact, impossible from a conceptual point of view. Surgeries themselves merely make for cosmetic alterations, but they cannot cause, for instance, a biological male to menstruate or to bear children. The (subjective) psychological experience of one possessing an internal disposition that departs from his or her phenotype cannot override (objective) biology, as we would then have to entertain any number of claims asserted on the grounds of potent feelings alone.
- Arguments that appeal to mental illness are likewise considered inapplicable in this circumstance. Individuals who suffer addictions, for instance, also possess a type of ailment, but the state of the drunkard and the habitual fornicator, Mufti Qāsmī points out, is not alleviated by intensifying their sinful activity and relaxing their moral obligations. It is the same in the case of the dysphoric individual, whose suggested cure of sex reassignment stands to intensify the underlying illness rather than treat it.
The fatwa concludes by attending to the question of one who has already undergone sex reassignment. In this case, the fatwa recommends a detailed account authored by the individual who has gone through the surgery chronicling his or her experience alongside a report from a reliable Muslim physician conversant with the procedure. From there, individual verdicts can be dispensed by a judge as to whether such a person should be treated under the Sharīʿa as a man, a woman, a dispositionally effeminate male (mukhannath), or an ambiguous hermaphrodite (khunthā mushkil).195
Like the Muslim World League and Darul Uloom Deoband, the top clerical body in Indonesia, the Indonesian Muslim Council (Majelis Ulama Indonesia, or MUI), issued a fatwa on the local waria community (warias are biological men who impersonate women).196 Issued in October 1997, the fatwa states, inter alia, the following:
- Car warias are, biologically speaking, unambiguously male, they cannot be regarded as an alternate gender.
- The behavior of the warias in imitating women is prohibited (ḥarām), and they must exert efforts to return to both the appearance and the behaviors (dress, affected mannerisms, etc.) proper to their natal male sex.197
The MUI fatwa concludes with an appeal to the Ministry of Health and the Ministry of Social Affairs to mobilize efforts to guide and assist warias psychologically alongside a second appeal to the Ministry of Home Affairs to dissolve a prominent waria organization (HIWARI MKGR).198
In Shīʿī Iran, things took a different trajectory, apparently due to the influence of psychologist ʿAlī Akbar Siyāsī’s pivotal work enunciating a dual conception of human identity that comprised badaniyyāt (anatomy) and nafsāniyyāt (feelings, thoughts, and reactions). This bifurcation apparently “provide(d) a way to address transsexuality as a psychological condition in Islamic terms.” In 1987, the Iranian Ministry of Justice, in response to a query from the Legal Medicine Organization of Iran, asserted that sex change surgery was religiously permissible (citing Khomeini’s writings as support), and the government moved to legalize it.199 Notwithstanding, the matter remains controversial among Shīʿī jurists. For instance, the prominent jurist Ayatollah Jaʿfar al-Subḥānī maintains that sex change surgery is prohibited except in the case of the khunthā mushkil (concurring, in essence, with the Sunni consensus as expressed by the Muslim World League fatwa). He interprets Khomeini’s endorsement of such surgeries as referring to the purely hypothetical case of a total sex change being possible. Al-Subḥānī points out that in reality, this could only happen by a divine miracle; all that surgery is capable of is a false and superficial change that does not alter the actual gender of the patient.200
Both Sunni and Shīʿī opponents of sex change surgery support their position—namely, that of default prohibition for other than necessity in the case of the khunthā mushkil—on the basis of the following:
- Qurʾān 4:118–119, which describes “changing God’s creation” as a Satanic act
- Hadith prohibiting mutilation of the human body (muthlā)
- Hadith prohibiting imitation of the opposite gender
- The fact that gender transition surgeries are fraught with scientific uncertainty regarding long-term effects and that anecdotal evidence suggests that they often do not bring notable satisfaction to patients
Given the aforementioned considerations, what conclusions can be drawn that account for the complexity of gender dysphoria, hormone therapy, sex reassignment, and related issues tied to the question of contemporary transgenderism?
Having sought counsel from a number of scholars on the matter,201 the steady conclusion we have found revolves around the subject of changing God’s creation, a prohibition known in works of fiqh as taghyīr khalq Allāh. This prohibition is based on several proof texts from revelation, including the verse of the Qurʾān in which Satan vows to misguide humanity by, among other things, “commanding them so that they change the creation of Allah.”202 This verse is coupled with a number of probative hadith in which the Prophet (ﷺ) speaks of God’s curse falling on those who “change the creation of Allah.”203
When viewed alongside prophetic reports about the curse on those who deliberately imitate the characteristics of the other sex, as well as revelation’s consistent and unmistakable classification of human beings as constitutionally and dispositionally either male or female, these texts support the inherency of gender as an immutable fact of our creation, notwithstanding the exceedingly small population of the khunthā mushkil, intersex individuals whose gender is completely ambiguous both anatomically and genetically. This conclusion is strengthened by the fact that the Sharīʿa acknowledges and accommodates those who are congenitally nonconforming in gait, speech, and other such behaviors but does so while upholding the reality of their underlying sex and, in fact, maintaining the vast majority of sex-specific sharʿī rulings (e.g., inheritance, marriage) on the basis of biological sex rather than internal disposition or outward behavior.
The argument for sex alteration on the basis of necessity (ḍarūra) remains unsubstantiated. The prospect of sex change surgery, hormone therapy, or puberty suppression successfully resolving suicidality and other symptoms of gender dysphoria is far too subjective, with post-transition studies reporting a persistence and, at times, even an intensification of suicidal ideation, self-harm, and other forms of anxiety and personal trauma. The conceptual and ontological impossibility of a true and complete sex change further buttresses this conclusion, as surgeries and related medical interventions at most yield cosmetic alterations that may succeed as strictly palliative measures. Ultimately, gender dysphoria—provided that intersex syndromes and disorders of sexual development have been ruled out—is a mental disorder, not a physiological abnormality. As such, it is something that requires proper psychotherapeutic care as well as familial and social support, not radical medical interventions carried out on a healthy, unambiguously male or female body.
Some of those experiencing gender dysphoria may fall partially into the categories of takhannuth (male effeminacy) and tarajjul (female mannishness). We recall that these categories refer specifically to innate mannerisms beyond a person’s conscious control. As such, they have always been distinguished from tashabbuh (lit. “seeking to resemble”), which involves the deliberate imitation of the opposite sex (traditionally manifested in things such as cross-dressing). As it stands, the primary manifestations of contemporary transgenderism—including sartorial and social transitioning, hormone therapy, and/or surgical interventions—fall into the category of tashabbuh, the ruling of which is one of prohibition.204 Dealing with transitioned or transitioning individuals in the community will require careful consideration by a qualified scholar who is aware of the person’s circumstances, communal arrangements, and related factors—though sharʿī rulings on sex-specific matters (such as marriage, inheritance, leading the prayer, etc.) would apply in conformity with the person’s biological gender.
Our research on transgenderism began over two years ago. In the intervening time, developments have occurred that have dramatically raised the stakes of the debate, particularly as it pertains to social and pedagogical reforms directed towards children. The United States Supreme Court has recently interpreted Title VII protections to extend to sexual orientation and gender identity (with amicus briefs having been filed both in support of and opposing the motion by different Muslim groups). Meanwhile, a school county in Minnesota is being sued by a family alleging discrimination for not allowing their socially transitioned child to use the bathroom corresponding to his/her gender identity (the student is apparently using a single-occupancy restroom, though such a compromise is alleged to be “isolating”), while a school district in Chicago, after a contentious hearing, recently passed a measure providing transgender students unrestricted access to the locker room of their choice. The list could go on, and hardly a week passes without news of a new county deliberating similar measures. Adding LGBT-themed books to school libraries and incorporating teachings into curricula that depict gender as a subjective social phenomenon have become staples of this culture war, and suburban districts throughout the country are moving forward with LGBT affirmation as central to their institutional commitments. Teachers, counselors, school administrators, and others are rapidly being coopted into this program, and anything short of full-fledged “affirmation” is henceforth regarded as latent bigotry that must be expunged from civil society.
The existing political atmosphere, characterized by an arguably unprecedented level of polarization that is regularly exacerbated by radical partisans, leaves little room for negotiation and reasoned compromise, so the discourse becomes more totalitarian, more tribalized, and zero sum. “Silence is violence” tells us that sitting out is irresponsible and morally reprehensible, thus pressuring those with conflicting moral views into cultural conversion. The now common appeals to “complicity” charge those with deeply held values opposing the LGBT agenda of sharing the blame in crimes committed by radical actors. If one is opposed to reforming school curricula in conformity with the latest LGBT pieties, then one shares in the deaths of innocent gay and trans citizens (“People are dying and here you are worried about a few books at the library that could have saved real lives!”). Over time, such rhetoric coerces all into either submission or silence.
In this study, we have taken great care to examine the various threads related to transgenderism. It is by no means comprehensive, but as a work geared to providing Muslims meaningful insight into the debates of the moment, the paper has sought to offer a substantial amount of material drawing on a wide range of research on the topic. This includes research highlighting gender dysphoria and contemporary debates over its origins, historical developments, controversies, and medical treatments. We have also reviewed recent treatments of sex change surgery by Muslim scholarly authorities and offered a concise presentation of their ruling (ḥukm) on it.
Though such an articulation is critical for Muslims, it is ultimately inadequate insofar as it does not offer nearly enough for those on the ground. The reality is that for the vast majority of people in the Muslim community, including imams, therapists, physicians, and parents, the topic of transgenderism represents uncharted waters. The majority of counselors and therapists in the Muslim community attend to domestic disputes such as rocky or failing marriages, child–parent tensions, eating disorders and related anxieties, and domestic violence. Some may occasionally find themselves dealing with Muslims who struggle with same-sex attractions, though even this bears little correspondence to individuals who have come to hate their own bodies, their genitalia, their identity, and how God made them—a boy or man whose few moments of ease arise when he wears makeup or dons female undergarments or begins to wear hijab outside the house, a girl or woman who agonizingly “chest binds” to suppress the protrusion of her breasts in order to appear more masculine. How can we minister to such people in a way that does not aggravate their alienation, trauma, and personal despair sans pour autant violating our core commitments as a moral community or entrenching their dysphoria further? Herein lies the million-dollar question.
It goes without saying that notions of gender fluidity are inherently relativistic, and this phenomenon is but a microcosm of the larger moral relativism prevalent in the contemporary West. Bearing this in mind, it becomes vital to address the notion of experiential knowledge as far as the topic of gender identity is concerned: “I have experienced this, and this is true for me. Until you have felt what I have felt and seen things through my eyes, don’t come and tell me otherwise.” No amount of rational discourse or rhetoric would make a difference in a context where emotions are volatile and traumas are involved, coupled with relativistic assumptions about the world devoid of any clear or fixed frame of reference. Absent revelation and a God-conscious discourse, people have the freedom to experiment across the spectrum and see what “works for them” at a given point in time. In other words, there are no limits to how a person may choose to manifest and express his or her own notions of sexual orientation or gender identity if there are no proper, objective foundations to fall back on. It follows from all this that proper individualized care for a person struggling with gender dysphoria must account for that person’s collection of experiences, emotional attachments, traumas, and individual perceptions, together with an integrated frame of reference necessary to build proper and sturdy foundations. Such a feat is, quite evidently, very challenging.
Some will no doubt propose to enhance the current focus on psychotherapy. If current trends persist, however, few counselors will be in a position to offer anything other than “affirmative therapy,” particularly if desistance is treated the same way so-called conversion therapy for homosexuality has been treated by clinical authorities. If at some point this prospect materializes in full, desistance therapy may well be formally outlawed as a practice in certain jurisdictions. Muslim chaplains, physicians, school administrators, counselors, and others would then find themselves in correspondingly difficult circumstances. Imams may retain greater professional latitude, though young Muslims are increasingly turning away from imams, treating them with suspicion, and are thus unlikely to take instruction from them on matters that, for many in the postmodern West, have become fundamental to their psychosocial identity. Within such a milieu, it will be nearly impossible for parents of children experiencing GD (as well as for adults experiencing GD) to find any reasonable guidance that does not reflexively commit to so-called affirmative care as a starting point. Parental and personal discomfort with such a prospect will be interpreted as bigotry and discrimination, old-world attitudes that are out of step with modern values of equality and tolerance.
This is all very alarming indeed. Short of independent bodies that can counteract the pressures of the prevailing discourse, Muslim families and their youth will forever be at the whim of the unpredictable shifts of liberal social sensibilities. In the meantime, families dealing with such issues will be largely on their own. There are some steps that can be taken in such cases, though these are highly discretionary and depend on the context and the individual in question. One may enlist help from family members, for instance, but care must be taken as such efforts can fracture relationships and lead to a deterioration in the integrity of the family altogether. Individuals experiencing GD must be approached with care, empathy, and understanding. In some cases, more of a “tough love” approach has been cited by some transgender individuals who ended up desisting from transitioning (bearing in mind that such an approach must be handled with emotional maturity and patience).205 The difficulties faced by an individual with GD should not be underestimated, and those struggling with such a condition should never be ridiculed or ignored. In light of the late Joseph Nicolosi’s theory regarding gender nonconformity, it would be prudent in a great many cases to examine factors such as abuse and childhood traumas, as these will need to be addressed for the affected individual to find wholeness and personal contentment. Almost all cases would benefit from a radical reduction in usage of the internet and social media, particularly venues that promote transgender ideology (which should be avoided altogether). It may also prove helpful to provide support groups of individuals of the same sex who can offer continuous emotional, spiritual, and psychological support and follow-up. More drastic measures may need to be considered if such problems persist. For example, it may be necessary to find a new physician if the existing primary care provider has been complicit in encouraging transitioning (particularly at the pediatric level). If the individual and/or his or her family is under the influence of counselors, lobby groups, or peer pressure, then it may be beneficial to relocate to another district, county, state, or region.
In the meantime, the Muslim community must invest in the resources necessary to help minister and care for those suffering from severe cases of gender dysphoria. There is a pressing need for counselors and therapists who, supported through Muslim community patronage, can practice their professions independently in accord with Islamic principles and an accurate appreciation of the medical studies and statistical data. Also required are imams capable of navigating transgender discourse in order to help parents understand what public schools are teaching their children and to administer appropriately to Muslims suffering from gender dysphoria and their families. In short, counseling, treatment, and guidance on these matters should ideally involve a multi-disciplinary approach involving religious scholars, counselors, therapists, imams, and medical professionals, all of whom would possess adequate knowledge of gender dysphoria in its various aspects and are firmly grounded within a normative Islamic framework. Finally, robust curricula must be developed for the teaching of an Islamic sexual and gender ethic, one that authentically draws on the Islamic legal, ethical, theological, and spiritual traditions while bringing them into conversation with the fraught agendas of gender fluidity and contemporary trans activism. Much of this work has not even started and in other cases remains severely underdeveloped.
In the end, there are no easy answers. Gender dysphoria will likely remain with us for the foreseeable future, and the number of cases will continue to rise as the social phenomenon of transgenderism grows. It will be essential to understand the complexities of the discourse, our religious obligations, and our moral imperatives and to develop robust and well-rounded therapeutic interventions as we look ahead. We ask God to help us undertake this task. Amin!
And Allah knows best.
An emerging theory of the brain’s interaction with cultural conditions may serve to offer an added explanation of the modifications to brain structure observed in studies of transsexuals. The theory was inaugurated with a paper published in 2015 synthesizing over one hundred studies and formulating what is known as the Culture-Behavior-Brain (CBB) model.206 The CBB model is an integrated framework which posits that culture, behavior, and the human brain dynamically interact with and influence each other in ways that are more explicit than previously understood.
The process of CBB modifications begins with an idea assimilated into a social setting. The more deeply entrenched the idea, the more it permeates a cultural understanding of the phenomena associated with it. Consider the emergence of “sexual orientation” in the nineteenth century or the coining of the term “religion” as a discrete concept that came into being in the sixteenth century. Prior to the introduction of these concepts, the manner in which the underlying phenomena associated with them functioned, as well as how people conceived of them, differed dramatically. Thus, the introduction of “religion” did not merely describe what already existed; it created a sphere of activity that could be detached from other institutional forces and that has come to shape how we now construe world affairs (i.e., the place of religion in the world) as well as the organization of society (i.e., religion vs. the state). The permeation of the concept of “sexual orientation” has had a similar effect by providing a discrete identity and cultural script such that someone who merely expériences same-sex sexual attraction comes to conceive of that attraction as definitional to his or her sense of being and corresponding self-worth. The idea of transgenderism, though a much more recent phenomenon, has had much the same effect in establishing a new taxonomy for gender nonconformity and providing a cultural script through which particular feelings are understood and subsequently acted upon. What CBB tells us is that once these cultural scripts establish themselves as uncontested understandings of specific happenings in the world, the brains of those experiencing phenomena derivative of that understanding actually alter in structure due to the brain’s inherent plasticity. Once this happens, the modified brain guides individual behavior to fit specific cultural contexts. Hence, culture, behavior, and the human brain interact dynamically through mutual connections, each influencing the other and changing continuously in the process. Human genes are integral to this process too, as they lay the groundwork for the structure and function of the brain as well as for behavior.
Given the myriad brain studies on transsexual and transgendered individuals and their conflicting results, and in light of the CBB model posited above, the following question must be raised: Are the supposed brain changes in transgender individuals part of the etiological factors leading to transgenderism, or are they a result of the interaction between the brain and a culture that accepts, nurtures, and pushes
for transgenderism (be that on a micro or a macro level)? And if they are in fact a byproduct of acculturation, does CBB offer a robust paradigm through which this change can be explained?
This very question is taken up in a paper published by Mohammadi and Khaleghi in 2018.207 After examining a multitude of brain studies along with their (often conflicting) results, the authors urge us to look at these studies differently. As we have noted, studies on genetic influences for transgenderism have not furnished reliable results, and this absence of genetic substantiation has been buttressed by the lack of organic differences in the brains of adolescents with and without gender dysphoria. The congruence of adolescent brain phenotype with natal sex has been accounted for by the lack of sociocultural awareness. In other words, it is argued, children lack a substantial appreciation of their own behaviors, likes, and dislikes—let alone an appreciation of transgenderism and what it entails—at a stage of their lives where their integration into existing gender roles is still an ongoing process. It is only after puberty that a full internalizing of regnant cultural conventions tends to occur and, as a consequence, the distinctions between brain phenotypes become more evident. According to this model, brain changes emerge depending on the strength and length of habituation after initial exposure to the psychosocial phenomenon of transgenderism.
This may also explain why many of the brain studies are contradictory, given that such changes rely on a myriad of external variables. In other words, when a biological male experiencing gender dysphoria elects to regulate his lifestyle based on a female gender identity, it is expected that the brain will adapt to this belief and corresponding lifestyle with time. Consequently, changes first in the function and then in the structure of the brain will occur.
Now, it is crucial to understand that brain plasticity works both ways: just as the brain can learn new ideas and beliefs and change accordingly, it can also, in principle, unlearn said ideas and beliefs and change back to its original state (or something close to it). Therefore, an individual experiencing gender dysphoria who is socialized within a setting that teaches transgenderism as an explanation of gender nonconforming thoughts can nevertheless unlearn the cultural script he or she has been taught, thereby attenuating prior brain changes and returning the brain to a state more congruent with his or her natal sex (which would, in turn, help further abate nonconforming thoughts). Though further study is needed, CBB may provide an initial framework for therapeutic efforts and support the idea that an effective cognitive reorientation—such as through cognitive behavioral therapy, or CBT, for instance—may be of help to those struggling with gender dysphoria. Such efforts, however, would have to be brought into conversation with Islam’s ontology of human existence, which recognizes that our physical being is inextricably tied to our psychic and spiritual realities.
Intersex is a term that refers to individuals born with sex characteristics that do not fit within physiological definitions of male and female sex.208 In other words, such individuals have variations in their genitalia, sex hormones, and/or chromosomes, leading to gender ambiguity. It is necessary to differentiate intersex persons from transgender individuals: while the latter experience gender dysphoria and have problems with gender identity on account of subjective personal experience, the former are objectively proved, through medical examinations and tests, to have an incongruence between their genetic sex and the physical manifestations thereof. This section expands on the etiology and manifestations of intersexuality and ties this in to the discussion of gender dysphoria.
During fertilization, the sperm adds an X (female) or a Y (male) chromosome to the X chromosome already present in the ovum (female egg). This results in an embryo with either XX sex chromosomes (a genetic female) or XY sex chromosomes (a genetic male). During embryogenesis, two sets of ducts develop that give rise to the human reproductive system: the paramesonephric (also known as Müllerian) ducts eventually develop into female internal reproductive organs (uterus, fallopian tubes, and the upper third of the vagina), while the mesonephric (also known as the Wolffian) ducts eventually develop into male internal reproductive structures (epididymis, vas deferens, seminal vesicles, and ejaculatory ducts). Up until approximately the seventh week of gestation, primitive sexual organs are not distinguishable between males and females. These organs develop later into either testes or ovaries, depending on the subsequent stages of embryogenesis.
Female sexual development is the default development in humans, whereby the paramesonephric ducts develop and the mesonephric ducts degenerate. However, if the embryo is genetically male, the Y chromosome (through the SRY, or testes-determining, gene on the Y chromosome) aids in the testes development process, suppressing the development of the paramesonephric ducts and stimulating the development of the mesonephric ducts. Hormones such as testosterone, produced by specialized cells in the testes, are necessary for the full development of the internal and external male reproductive organs. By birth, the typical baby can be visually distinguished as male or female, with internal and external sexual organs congruent with the child’s genetic sex.
Along the path of normal embryonic development, however, some problems can occur that impede this natural scenario. Such occurrences are classified as disorders of sexual development, or DSD. These disorders can be chromosomal: some human embryos do not have the normal set of 46 chromosomes (i.e., some may have an extra or a deficient number of sex chromosomes). Other disorders are not chromosomal: individuals may have the normal set of 46 chromosomes and, hence, from a genetic perspective are unambiguously females (46,XX) or males (46,XY), but due to issues with pathways of the sex hormones, discrepancies can arise whereby the external genitalia do not match the genetic sex and internal organs. As a result, some individuals can be genetically male but born with female or ambiguous external genitalia or genetically female but born with virilized (that is, masculinized) or ambiguous external genitalia. Upon suspecting disorders of sexual development, physicians nowadays order a series of tests that determine a person’s genetic makeup as well as the presence or absence of internal sex organs to arrive at a proper diagnosis whenever possible.
Money et al., in 1955, proposed the concept of psychosexual development.209 As shown by animal experiments, sexual differentiation is not completed with the formation of the sex organs; rather, the brain also undergoes sexual differentiation consistent with the other characteristics of sex.210 This paradigm suggests that in the case, e.g., of males, androgens (male hormones)—either directly or via local conversion into estradiol (a female hormone)—organize the brain in early development, while pubertal hormones, at the time of puberty, “further activate and reorganize the already organized brain, resulting in the expression of masculine behaviors.”211 Two peaks for testosterone, in mid-pregnancy and during the first three months after birth, are thought to organize and entrench the neural circuits in the brain for the rest of a male individual’s life.212 It seems that rising testosterone levels during puberty then activate and reorganize these pathways. Traditionally, psychosexual development has comprised three domains: (1) gender identity (sense of belonging to and identification with one’s gender and people of the same gender), (2) gender role behavior (behaviors and traits designated by society as appropriate for males or females; the specifics of these are culturally and historically bound), and (3) sexual orientation (a person’s responsiveness to sexual stimuli, mainly the sex of those to whom one is sexually and/or romantically attracted).213 It can thus be seen that human sexual differentiation is a multidimensional and sequential process.
Any perturbation occurring during the complex process of sexual differentiation described above can lead to a misalignment between chromosomal, gonadal, and phenotypic sex, classically defined as a disorder of sexual development (DSD). In individuals with DSD, the three components of psychosexual development we have mentioned—gender identity, gender role, and sexual orientation—may not always be concordant or aligned.214 As sexual differentiation of the reproductive organs takes place earlier in human development (namely, in the first two months of pregnancy) than sexual differentiation of the brain (which occurs in the second half of pregnancy), these two processes may be influenced independently. So, in the case of ambiguous genitals at birth, the degree of, e.g., masculinization of the genitals may not always reflect the degree of masculinization of the brain.215
Psychosexual development thus appears to be a complex and long-term process affected by brain structure, genetics, in utero216 and postnatal hormones, environment, and social and familial circumstances.217 Arguably, after ruling out intersex syndromes and biological factors that may have contributed to DSD, it becomes evident that a person’s environment, including social and familial circumstances, plays a crucial role in appropriate psychosexual development, accounting for the majority of DSD cases with misaligned components of psychosexual development.
Congenital adrenal hyperplasia (CAH).218 The most common DSD, congenital adrenal hyperplasia consists of an autosomal recessive disorder219 that leads to deficiencies in key enzymes involved in the pathway of steroid hormone production in the adrenal glands. Depending on what role the enzyme plays and the severity of the block in production, disease presentations in affected individuals can vary. Many forms of CAH exist, the most common of which is 21-hydroxylase deficiency, which may present during infancy as a salt-wasting adrenal crisis, or later during childhood as early precocious puberty and virilized external genitalia (in females) due to high levels of circulating male sex hormones, or androgens. Another form is 17-alpha-hydroxylase deficiency, in which the production of sex hormones is impaired. Genetic females thus lack female secondary sex characteristics at puberty, while genetic males have ambiguous genitalia with undescended testicles and can therefore be confused for females.
Androgen insensitivity syndrome.220 Also known as testicular feminizing syndrome, androgen insensitivity syndrome describes an X-linked genetic disorder occurring in genetic males whereby a defect in the androgen receptor results in the body’s not responding to testosterone in the way it should, resulting in a variety of disease manifestations. In the complete form of this syndrome, a genetic male appears as a typical female, with breast development and female external genitalia; such individuals live as females and are unaware of their condition until puberty, when they fail to menstruate. In the mild form, a genetic male has normal male external genitalia, accompanied by infertility and/or enlarged breasts. Finally, the partial form of this disorder is marked by a spectrum of undervirilized external male genitalia. Depending on the precise form of the syndrome, issues related to sex assignment, removal of the testes (due to the risk of developing tumors), fertility, and psychosocial outcomes must all be taken into account in the treatment process.
5-alpha-reductase deficiency.221 This autosomal recessive disorder occurs in genetic males, whereby an enzyme responsible for converting testosterone into dihydrotestosterone—a potent androgen responsible for male sexual development during the fetal period and later during puberty—is lacking. The deficiency in this androgen leads to various forms of undervirilization of the external genitalia in genetic males (ranging from feminine or ambiguous genitalia to a micropenis). Most often, these individuals are raised as females until they reach puberty, where an increase in the levels of androgens leads to the development of some male secondary sexual characteristics, such as increased muscle mass, deepening of the voice, development of a male pubic hair pattern, and a male-typical growth spurt.
Aromatase deficiency.222 Aromatase is an enzyme that is involved in the synthesis of estrogens (female hormones) from androgens. Aromatase deficiency is an autosomal recessive disorder that results from a gene mutation leading to maternal virilization during pregnancy (the fetal androgens can cross the placenta and lead to symptoms in the mother), as well as fetal virilization of the external genitalia. Genetic females are thus born with virilized or ambiguous genitalia, with high levels of circulating androgens.
Klinefelter syndrome.223 This refers to a genetic male with an extra X chromosome (i.e., 47,XXY). Klinefelter syndrome is reported to occur in 1 in 600 male births, approximately sixty-four percent of which remain undiagnosed throughout life. Typical characteristics include a eunuchoid body shape with tall and long extremities, female hair distribution, enlarged breasts, cognitive and developmental delays, and infertility.
Turner syndrome.224 Unlike Klinefelter syndrome, where a genetic male has an extra X chromosome, in Turner syndrome, a genetic female lacks an X chromosome (hence, she is 45,X). This occurs in 1 in 2,500 female births. Females with Turner syndrome generally have short stature, a short neck, and a broad chest and are at higher risk of developing cardiovascular, skeletal, and autoimmune diseases. Almost all females with Turner syndrome are infertile.
True hermaphroditism (ovotesticular disorder of sex development).225 This is a very rare congenital anomaly characterized by the presence of both testes and ovaries in the same individual. Most commonly the individual would be a genetic female (46,XX).
There are many other conditions and syndromes that exist under DSD, but from the few selected examples, one can appreciate that chromosomal or hormonal imbalances can often lead to a wide variety of physical presentations where the regular definitions of male and female do not quite fit. Nowadays, in newborns found to have virilized or ambiguous genitalia or any secondary physical signs or symptoms typical of patients with such disorders, a set of tests is usually ordered to reach an appropriate diagnosis. Procedures such as a blood test to check for circulating estrogens and androgens, karyotyping (observing the complete set of chromosomes in the individual to determine any chromosomal abnormalities), and an abdomino-pelvic ultrasound are quick and easy tests that can serve as a starting point for further investigations.226
Of course, not all these disorders are diagnosed at birth, as some of them may only manifest during adolescence. Whether at birth or later in life, gender uncertainty is quite unsettling and may result in psychosocial and familial problems. Factors that influence the determination or assignment of gender include the diagnosis itself, genital appearance, surgical options, fertility potentials, and the need for lifelong hormonal replacement therapy, as well as cultural, familial, and, of course, religious considerations. Sometimes the person’s gender is quite obvious, as in the case of genetic females with congenital adrenal hyperplasia, where more than ninety percent of patients live as females (in congruence with their biological gender). Biological males with complete androgen insensitivity syndrome, assigned as females in infancy, will usually identify as females. In cases of ovotesticular disorder (that is, true hermaphroditism), issues to consider include fertility potential based on differentiation and development of the genitalia, as well as the degree to which the genitalia are, or can be made, consistent with the chosen sex.
Other than surgical interventions called for depending on the individual diagnosis, individuals may require hormonal therapy to induce puberty (including secondary sexual characteristics, a pubertal growth spurt, and optimal bone mineralization), as well as psychosocial support for psychosexual maturation.
It has been suggested that gender dysphoria is, in a sense, a subset of DSD, one limited to the brain and without the involvement of the reproductive tract.227 According to DSM-5, gender dysphoria is a condition characterized by a marked incongruence between one’s experienced/expressed gender and one’s biological sex, associated with clinically significant distress or impairment in social, occupational, or other important areas of functioning.228 The overlap between gender dysphoria and DSD lies in the possibility of experiencing discomfort in the discrepancy between one’s sex as determined at birth and one’s gender identity, which can eventually lead to a request for sex reassignment. The difference between DSD and gender dysphoria, however, lies in the consideration of biological sex indicators: sex chromosomes; sex-determining genes; genitalia; systemic sex hormones during fetal development, puberty, and adulthood; and secondary sexual characteristics. In gender dysphoria, all these biological indicators point in the direction of one’s biological sex, while one’s gender identity points in the opposite direction. In DSD, the misalignment also involves these biological sex indicators. This distinction has also been emphasized in DSM-5.
Gender identity problems and subsequent gender reassignment may occur later in life in persons with DSD, the context of which is different from that of non-DSD individuals.229 The question of how gender assignment at birth should be decided in cases of individuals with DSD so as to minimize the later development of gender dysphoria and gender change is very controversial and subject to ongoing debates in clinical management policymaking circles. Such gender identity problems are not universal, and when they develop, they may not occur before adolescence or even adulthood. Female-to-male is more frequent than male-to-female gender change in DSD patients; likewise, gender change is more common in syndromes with relatively high androgen exposure, suggesting an indirect influence of androgens on gender identity development. Hence, there are very marked variations between syndromes of DSD with respect to the prevalence of individuals who are not satisfied with their assigned gender and who eventually choose to undergo gender change.
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