Let’s Talk About Transgenderism

A few years ago, I attended The World Professional Association for Transgender Health (WPATH) conference in Chicago. Even as a medical/surgical professional, I admittedly did not know enough about transgenderism to adequately meet the needs of the occasional trans person who showed up in my clinic. Being open-minded wasn’t enough. I needed information regarding statistics, biology, physiology, psychology, sociology, and the culture of the transgender community. And at that meeting, I found what I was looking for. I learned a lot, but one thing surprised me; there were a lot of trans medical professionals at the conference, and I couldn’t identify who was trans and who wasn’t. I had always thought I would know it if I met a trans person, that something would give it away. But I was mostly wrong about that, and wrong about lots of other things I had assumed about the trans and non-binary community.

I’d had a lot of exposure in medical school at the Oklahoma Children’s Memorial Hospital to the plight of parents who had given birth to a child who was intersex (One who has an unknown sex due to ambiguous genitalia). As everyone knows, we used to wait until the baby was born and then announce, “It’s a boy!” or “It’s a girl!” based on whether or not a penis was present. With the advent of ultrasound, parents today are usually informed of the sex of the baby before birth. Sometimes, however, it’s hard to tell on ultrasound. And sometimes the reason for that is that the baby is intersex. There are a number of genetic conditions and hormonal conditions that can cause this to happen, as we all start out as embryos with the precursor structures to morph into either a male or a female, but any interference with the expression of the genes or influence of the sex hormones that direct the embryo to develop one way or the other can result in an atypical appearance of the genitalia. Then the medical team has to rely on other tests to determine the genetic sex of the infant, like DNA tests to determine the presence of sex chromosomes, and blood tests to determine if the infant is missing a critical enzyme that is required for the normal physical effects of testosterone or estrogen. A baby that appears to maybe be a girl might be a boy, and vice versa.

The management of intersex cases can get tricky. In the past, all such infants were assigned “female” and, if necessary, surgery was done to fix the abnormal genitalia, so it looked female, even if the baby was genetically a boy. This approach proved to be wrong, as it didn’t take into account the baby’s gender. Gender, the sense of being masculine, feminine, both, or neither, is determined in the brain of the newborn, and it too is influenced by sex hormones and sex hormone receptors in the embryo as it develops into a fetus and then a baby. The development of the sense of one’s gender can also be influenced by medications or exposure to environmental pollutants which mimic the chemical structure of sex hormones. The sense of one’s gender is also definitely influenced by the culture around a person and the expectations of society. In a society that does not condemn gender fluidity and recognizes that there are ranges of maleness and femaleness, the small number of gender fluid or transgender people may be recognized and respected in society and may sometimes have special roles in society. In a society that refuses to recognize that some people do not fit the male/female gender appearance and roles, those affected are forced to conform to social and behavioral customs deemed suitable for their apparent sex by the prevailing culture. If they look like a boy, they must act like a boy. If they look like a girl, they must act like a girl, otherwise they are mistreated. Such societies fail to take into account that there are at least four sexes – male, female, intersex, and none-of-the-above; and there is a wide range – or spectrum – of genders.

Some people have a gender that is called “non-binary.” They either feel both male and female, or sometimes neither. The term “the binary” means the assumption that everyone is one of two possible things – male or female. So, the term “non-binary” means the person’s sense of gender is on a spectrum between male and female or is something else entirely. “Gender fluid” is a term that means a person’s gender is not fixed and is changeable. All of this is, obviously, in the brain. The apparent visual sex of the individual is neither here nor there in the case of gender fluidity or non-binarism – it’s irrelevant to how the person identifies their gender or knows themself.

Sexual orientation is a term that indicates the sex of the types of persons one is attracted to biologically and emotionally for an intimate love relationship. A straight (heterosexual) person will be attracted to the opposite sex. A gay (homosexual) person will be attracted to the same sex. A bisexual person will be attracted to both sexes. A pan-sexual person will be attracted to all sexes and genders. An asexual person is attracted to no one in particular. Put all together, these terms pretty much cover the range of possible intimate relationships a person can have.

A trans person is one whose self-perceived gender does not match up with their biological (genetic) sex. Their brain has been influenced by sex hormones, and probably atypical gene expression, in a way that makes it misaligned with the body in which it exists. A brain that senses it is female finds itself in a male body, and vice-versa. The sense of one’s gender is influenced entirely by how the brain develops under the direction of genes and sex hormone receptors, so even though this concept of misalignment sounds preposterous to most people, it is certainly not. In fact, it would be expected to happen with some frequency.

As a society, we have been taught that there are only two possible sexes (M/F), only two possible genders (M/F), and only one correct sexual orientation – heterosexual. Everything else is “abnormal.” It is assumed that everyone has either male or female genitalia and internal reproductive organs. Our society is built upon these mistaken notions, notions that are hammered into our heads from birth by uninformed parents and educators, and religious organizations that demand conformity. Yet throughout human history, and through no fault of their own, those who do not conform to the norm of the binary have always existed. Ironically, it’s the binary – the cisgender heterosexuals who are primarily responsible for giving birth to the population of LGBTQ people. It has always been the case – and will always be the case – that about 10% of the population will not be the “norm,” and that the genetics and physiological characteristics of the heterosexual population is responsible for that. LGBTQ people do not choose to be LGBTQ; rather, they simply choose to stop hiding. There are not more than there used to be.

People seem surprised nowadays that there are “suddenly so many trans people.” The reason this is the case is simply that society was finally actually beginning to make space for them in America in the past decade. Because of their increased visibility, there has been a backlash by conservatives who don’t understand what a trans or non-binary person is. There are many conspiracy theories regarding the imagined phenomenon of increased numbers of trans people – but the primary one is that children are being indoctrinated at school to be trans. This is not the case, of course, but the theory has been politicized and used as a scare tactic to convince people to vote Republican, since conservative Republicans don’t want any letter of LGBTQ to exist. The politicization of transness has resulted in an increase in attacks on trans people, an increase in suicides by trans people, and an increase in discriminatory legislation designed to make it difficult if not impossible to live as a trans person in America. The idiotic bathroom bills to force trans people to “use the bathroom that corresponds to their sex at birth” are perhaps the most obvious consequence of the fearmongering promulgated by the conservative Republicans and religious conservatives. Restriction of access to necessary gender-affirming care for young people is another.

Are there really more trans-people than there were in the past? No. They comprise only 1% or less of the overall population. The reason there seems to be “more” is that they are simply refusing to live their lives as the wrong gender. Medical management has advanced to the point where medical and surgical transitioning to make the body match the brain (the sex to match the gender) has been standardized, and because of advances in civil rights occurring from the 1990’s to the 2020’s it has been somewhat safer for trans people to be seen. They finally got a little relief from new laws that protected them. But now that is all being undone. Why? Because of fear. People who haven’t bothered to learn about gender and sex are freaked out about the “sudden” appearance of trans people in the public arena. Part of the problem is that it’s usually nearly impossible to identify a fully transitioned transgender person, and this bothers uninformed people. They imagine they are everywhere, as once transitioned they often easily pass for the gender and sex they now appear to be. You usually can’t tell who is or isn’t trans or non-binary unless they want you to know. Thus, the invasive bathroom bills. Conservative Republicans want to out all trans people so they are seen, but not for good reasons. They (white, heterosexual, conservative men) want to see them so they can verbally, emotionally, and physically abuse them and have them locked up. The comedy of this, of course, is that those who are so determined to “out” trans people in the bathroom actually cannot do it; it would require a full medical workup in the bathroom with a DNA analysis, and even then, they likely couldn’t tell a trans person from a non-trans person or intersex person even if they were a physician. The law is thus unenforceable and prone to serious mistakes, like accusing a masculine appearing woman or feminine appearing man of being a trans person in the wrong bathroom. (This has happened repeatedly – cis men and women are being harassed in bathrooms by white Republicans.) So, what do the legislators do to get around this? They write their laws so that the trans person is required to walk into the bathroom that matches their sex chromosomes, not their gender. When a transitioned or transitioning trans person walks into a bathroom that matches their sex assigned at birth, they look out of place, so it immediately makes it obvious they are trans, because they look like what they are – a (trans)female in a men’s bathroom or a (trans)male in a women’s bathroom. Had they gone to the bathroom that matched their gender rather than their sex, no one would have noticed. Needless to say, a transman in a women’s bathroom or a transwoman in a men’s bathroom is going to cause a lot more alarm to the other bathroom patrons than if they had gone to the bathroom that matched their gender. After all, a beautiful transwoman in a men’s bathroom is simply going to look like a beautiful woman in a men’s bathroom. Likewise, a handsome transman in a women’s bathroom is simply going to look like a man in a women’s bathroom. The whole concept of policing bathrooms to “protect the public” is thus beyond ridiculous.

“Well, we want our women to be safe!” scream the conservative white heterosexual men. Hmmm, I think to myself. Safe from what? You are literally sending a man into a women’s restroom and a woman into a men’s restroom with your legislation. YOU are doing this – forcing the trans person into the wrong restroom so you can identify them. YOU are causing a problem where none previously existed. The argument from the white heterosexual conservative side is that trans people will sexually assault the regular men or women or children in the bathrooms. When has that ever happened? Name a single case – I dare you. The incidence in police reports from around the world is literally ZERO! Not even a single case! But how many trans people have been sexually assaulted by non-trans people in bathrooms? In high school bathrooms, 36% of trans teens were sexually assaulted last year. And 9% of adult transgender people were assaulted in public restrooms in the past year. Over 500 assaults were officially reported in each of the past two years based on gender identity, with 35 homicides in 2023 alone. And it would be a lot higher if it weren’t for the fact that many assaults go unreported and trans people go out of their way to avoid public restrooms and other risky places for fear of being assaulted. And who is assaulting them? Any guesses? Straight white conservative men and women.

So, who is really the problem here? The trans people, or the people writing the bills to police them and try to ruin their lives? The answer is obvious. Social conservatives want LGBTQ people to go away. They don’t want to see or hear about them, and they certainly don’t want any of their kids to be in this minority group. I’ve said it before, and I’ll say it again, though, cis-straight people: if you want queer (LGBTQ) people to disappear, there is only one way to make it happen. YOU have to stop having sex and reproducing. YOU are giving birth to LGBTQ people. YOU are the source. LGBTQ people are born, not made by society. All society can do is oppress or support people born into this group, and cis-straight social conservatives are hell-bent on oppressing them. It won’t work. No matter what you do, LGBTQ people will still exist. If not in full view, then in hiding. You want to go back to the “great” days when all such people were constantly abused. A better choice would be to move forward with better education about sex, gender, and sexuality and fold this group of people into society properly. Do some good in the world. Stop being so mean to people.

I spent the last fifteen years of my surgical practice working with transmen and non-binary patients. I did a great job with their top surgeries, and I never – and I mean never – had a group of people so happy after surgery. Their lives were transformed for the better by gender affirming care.

I admit that it is hard to get one’s mind around the fact that a person who appears to be a man or woman might be the opposite. It was hard for me as a surgeon. It’s incredibly hard for parents who have attached themselves to a child of an assumed gender only to discover they’re actually the opposite. It creates an enormous amount of cognitive dissonance. People are scared of things they don’t understand.

I have met a lot of trans and non-binary people, and I have one trans friend. My attitude is that we are all people – human beings – and being kind and respectful to each other is not that difficult. Nor is it difficult to understand that no laws should ever be made by the government at any level to deliberately harm or oppress any particular group of people – this is not what a government is for. Nor should it be difficult to understand that religious belief should never be used to harm or oppress other people – I’m talking to you, Evangelicals, Christian conservatives, Muslims, and conservative Jews. Nor should it be difficult to understand that we all have the right to live our lives as best we see fit, and that none of us have the right to interfere in another person’s personal business. It is frankly disgusting how certain groups of cis straight religious people seem to think they have the right to interfere in the personal intimate lives of others. This should not be allowed in a country where “freedom” and the pursuit of life, liberty, and happiness is guaranteed by the Constitution. If you don’t like the idea that some people are some sort of LGBTQ, then shut up and mind your own business and don’t hang out with them. It’s that simple. Better yet, do some serious reading and make friends with LGBTQ people when you meet them so you can get over your anxiety about them. It’s not that hard to incorporate them into your friend or acquaintance circle. They are regular people.

Some today argue that middle-schoolers are jumping on the bandwagon of being non-binary or trans due to peer pressure and they are afraid that such kids are not really trans or non-binary, but rather, are enduring hormonal changes due to puberty that can sometimes result in confusion about gender. I understand that concern. I have wondered the same thing myself. Puberty is not any fun, and the high levels of sex hormones make you feel like you’ve lost your mind. I remember a couple of years there (age 12-13) where I didn’t know what the hell was going on at school or anywhere else, my brain was so overwhelmed with testosterone. However, I never ever felt confused about my gender or sex. Everything matched, and the reaction of my brain to the hormone storm of puberty simply reinforced that I was a cis male. This is the experience of most people, I think, though I don’t think it’s necessarily so clear for some, and this has to be taken into account.

The concern of misidentifying one’s gender as a child or in the teenage years is, I think, legitimate, though I have no data to prove it. But medical professionals do not want to make a mistake when it comes to kids who present to them with gender identity issues. This is why physicians and other medical professionals have established protocols to protect and prevent mistakes by limiting hormonal treatments and delaying them, when appropriate, until adulthood. Sometimes, however, the patient’s situation is such that it is critical they be treated early, beginning with counseling and therapy, and followed by hormone blockers (to prevent puberty from kicking in) and eventually hormone replacement. If surgery is desired, it is always delayed until adulthood, if it occurs at all. Most trans men will have top surgery (breast removal with creation of a male contoured chest). If they don’t, they simply bind and flatten the breasts so their chest appears to be male. Trans women can usually rely on hormone replacement for breast growth and don’t need top surgery. Many trans people elect not to have any genitalia surgery at all, especially trans men, due to the difficulty of making functional male genitalia. Hormonal treatment with testosterone does, however, cause clitoral enlargement to the point that it can function as a small penis, and there are other apparatuses that can help with sexual function without surgery. Those who choose to have “bottom” surgery to complete the transition from male to trans-female have more options, and the surgery has been refined to the point that it is often not possible to tell it was even done. Either way, bottom surgery is more complicated and more prone to complications, so it is often not done at all. This is, of course, nobody’s business, and should never be discussed by anyone except the trans person and people they may be dating. Asking someone “what’s down there” is overstepping to an outrageous degree. Would you ever ask that question to a regular man or woman you have no intention of considering as a date or possible intimate partner? No. You would not, unless you’re immeasurably uncouth. In any case, surgical transitioning for gender dysphoria has always been delayed by the surgical community until young adulthood; it has, to my knowledge, almost never been done in the United States for anyone under the age of eighteen. The average age for starting surgical transitioning is between 30 and 36, with a range of ages from 19-40. The regret and detransitioning rate is less than 5%, and the primary reason for detransitioning in this group is societal and family pressure, not regret from identifying as gender atypical.

I want to acknowledge the fact that most people – including me – feel uncomfortable with the idea of transness and unclear genders. Had I been taught about this when I was a kid, and had I grown up in a society that acknowledged these folks in a respectful manner, I don’t believe I would be uncomfortable about it still today. The same holds true for all the other queer letters. You can’t grow up in a society that fails to recognize the value of a whole group of people and deliberately oppresses them without becoming an oppressor yourself. Once you know better, though, you can change your attitude. It’s amazing how many people who have real biases against the LGBTQ community can give them up when they are directly affected by learning that someone they love – a friend, a family member – is a member of that community. A sensible person realizes when it’s time to learn more and re-think biased attitudes they have been taught, regardless of the subject of the bias. We become better humans when we pause and study an issue with intellectual curiosity rather than just following the status quo of the culture.