Transgender debates and healthcare: A critical realist account

Disputes about pediatric transition

The assumption that gender is assigned at birth and might be reassigned if a person is distressed by that description (an experience dubbed “gender dysphoria”) is the starting point for gender-affirmative pediatric practice. The distress is an affective state linked in clinical discourse to the young patient feeling that they were “born in the wrong body” or that their current sense of who they are is not aligned with their natal sex (cf. Brunskell-Evans and Moore, 2018).

Gender clinics for children and adolescents emerged in the Netherlands in the 1990s and their service philosophy of gender affirmation has been replicated and modified liberally in many European and North American contexts (de Vries and Cohen-Kettenis, 2012). Supported by professional guidance (e.g. British Psychological Society, 2019), psychologists and psychiatrists assessing gender non-conforming children routinely diagnose gender dysphoria, affirm the self-identity of the child, and then refer on to endocrinology services. The latter then prescribe puberty blockers and then eventually, as adolescence is reached, cross sex hormones. In young adulthood genital surgery is then in the offing.

Those objecting to gender affirmation, note a number of consequences of this policy (Cohen and Barnes, 2019; Levine, 2019; Saad et al., 2019; Stagg and Vincent, 2019; Steensma et al., 2017). First, initial hormone treatment to delay puberty tends to lead to a long-term use of cross sex hormones. Second, the latter bring with them iatrogenic risks. Third, children may agree to being medicated despite their limited cognitive capacity. Fourth, those patients, who also proceed in young adulthood to genital surgery, run the risk of procedural errors and infection, which might be life threatening. Fifth, a proportion of those agreeing to surgery then regret the decision and complain about a lack of fully informed consent. Sixth, children referred to gender clinics are disproportionately likely to have marked autistic features or come from dysfunctional familial systems.

In response to these criticisms, advocates of current practice argue that hormonal treatment respects the human right to gender self-identification, reduces the risk of suicide, and creates mental health gain. In turn, those claims are contested by critics (see below) and so an unresolved dispute about the legitimacy of pediatric transition has emerged.

Medical records and sex-based pathology

The conceptual contention about sex and gender has created a dilemma for healthcare policies, procedures, and protocols. On the one hand, arguments for self-identification have led to gender being recorded in the NHS. On the other hand, pathology is sometimes very clearly sex-linked. A transman cannot develop prostate cancer, so their screening would be illogical. The same point applies to gynecological risks and treatment, given that transwomen (with or without genital surgery) will not menstruate, give birth or suffer or die from uterine or ovarian pathology. For these reasons the routine recording of the ontology of sex recognizes that it cannot be simply conflated with gender as a personal and social ascription. For now, in the UK NHS providers might record both sex and gender but how standard that procedure is in practice is currently unclear (Dahlen, 2020).

Another relevance of recognizing the ontology of sex and the risks of conflating it with gender is that natal males and females have different health trajectories. At birth males exceed females in number but have a higher rate of mortality in infancy. Men tend to die younger than women (though the latter have more morbidity arising from long-term conditions). Some of these sex differences are shaped by socio-economic factors such as occupational risk, as well as gendered behavioral norms (e.g. violence, substance misuse, and smoking). However, there are other risks created by the existence of the Y chromosome, especially alterations in the immune response typical in each sex (Moalem, 2020). This has become evident in the recent COVID-19 pandemic. Male deaths have exceeded those of females by a ratio of 2:1 (http://globalhealth5050.org/covid19/), even though women have been exposed disproportionately in services industries, including healthcare, to the virus. The sex differences accounting for COVID-19 deaths are reviewed by Mauvais-Jarvis et al. (2020).

For these reasons, sex-linked pathology is important for both healthcare planning and individual clinical case work. This reveals in practice (rather than as a metaphysical abstraction) that gender cannot reasonably displace, or be conflated with, sex as a consideration in healthcare decision making and health policy formation: more on this now.

Controversies about trans healthcare

Trans affirmative advocates emphasize that transgender patients are subject to discrimination in healthcare, as in wider society (Heng et al., 2018). However, the “demand” side is not homogenous: some trans people want more medicalization and some want less. In the latter regard Cabral (2017) explains why s/he is not a disorder. Moreover, an international campaign has emerged to de-pathologize trans phenomena. The International Network for Trans Depathologization and its “Stop Trans Pathologization” campaign (http://stp2012.info/old/en/manifesto) is an example of the lack of homogeneity within identity politics.

A minority of trans people consider that dysphoria reflects an authentic existence, as part of the trans experience, and so it requires forbearance not medicalization (http://www.sjwiki.org/wiki/Truscum). Others though seek a full biomedical solution to their existential dilemma (i.e. transsexuals who anxiously seek full reassignment, which is then gratefully received). However, some patients only seek a partial version of this (e.g. by taking hormones but declining genital or “top” surgery). Both of these groups engaging with healthcare might express frustration at the speed and adequacy of their expressed needs being met, indicating the blurred line now between human rights claims and shifting norms about healthcare consumerism.

What makes the biomedical transition unusual is that it might prompt the extensive use of medical interventions, even though there is no physical morbidity recorded. However, this is a matter of degree: there are a range of healthcare scenarios in which cosmetic surgeons respond to the expressed needs of patients. Nonetheless, the divisions within the transgender community about biomedicalization, along with the protests of gender critics poses a central question: is transgenderism a medical condition at all and if it is then how is to be diagnosed? And if it is a medical condition then should the expressed needs of patients simply determine treatment plans?

The guidance about trans patients is provided by the World Professional Association of Transgender Health (WPATH), reflecting a consensus by experts (clinicians and academics who work in gender clinics and university gender studies departments). This guidance itself is controversial, with critics noting the ideological push from these interest groups and the poor quality of evidence underpinning guidelines created by vested clinical interests (Ioannidis, 2018). WPATH also make the contradictory recommendation of fully informed consent, in order to weigh up iatrogenic risk, alongside a “hormones on demand” proposal (Levine, 2019).

When Gender Identity Disorder was introduced into the Diagnostic and Statistical Manual (Third Edition) (American Psychiatric Association, 1980) it was met with extensive opposition from feminist clinicians (Bryant, 2006). They objected to the pathologization of “masculine girls.” This diagnosis has now been dropped from DSM and replaced only with the vaguer self-reported state of “gender dysphoria.” Feminist objections were summarized by Lev (2006) who argued that DSM had ignored “forty years of feminism,” referring to DSM-IV-TR diagnostic criteria for Gender Identity Disorder as the “clinical reification of sexism.”

Trans affirmative lobbyists have argued, in contrast, that trans patients should, like anyone else, be treated respectfully and equally but, in addition, their special needs should be taken into consideration (Heng et al., 2018; Pearce, 2018). Apart from access to hormonal and surgical procedures, other adjustments would include the medical management of transmen to conceive and give birth. Within budget-constrained healthcare systems, any response to special needs from a particular group of patients creates opportunity costs that affect others, which has been noted in relation to transgender healthcare (Koch et al., 2020). We see here a tension between an aspiration for open-ended “inclusivity” in healthcare policy and the economic constraints of resource allocation. The latter invites competition between clinical specialties, with their particular service user groups, which may go on to become consumer lobbies. (Alford, 1975)

The costs of healthcare include the management of clinical iatrogenesis, when and if it arises. In the case of “transgender healthcare,” these medically created adverse effects of disrupting endocrine functioning, include infertility, depleted bone density, and cardio-vascular events. As was noted earlier, the surgery entailed in transitioning and de-transitioning carries iatrogenic risks. For example, in the follow up of the 55 patients involved in the prototype Dutch service for children and adolescents, one of the patients died of postoperative vaginal fasciitis (de Vries et al., 2011).

Estimates of the rates of those requesting de-transitioning vary widely and this has led to calls for more debate about the ethical and legal implications of the process for health professionals and policy makers (Butler and Hutchinson, 2020). The current WPATH guidelines, noted above, do not cover the challenges for all parties of de-transitioning. This is despite the evidence that a majority of young transitioners, taking hormones alone, soon decide to affirm both their natal sex and their homosexuality (de Vries and Cohen-Kettenis, 2012).

The physical risks created by hormonal and surgical interventions are compensated for in the view of trans-affirmative advocates by the clear mental health gain from transitioning. Suicidality has been used as a marker of this gain but as with so much in this field, this has been challenged on methodological grounds. For example, Olson (2016) argued that transitioning children with parental support have the same levels of psychopathology as controls. However, a review of her raw data undermines that claim (Schumm and Crawford, 2020).

The distress of transgendered people is extremely difficult to disaggregate from their familial contexts as children and their daily social exclusion and stigma as adults. These biographical contingencies might render their higher rates of psychopathology intelligible. However, that view has also been contested by those noting the ongoing high rates of psychopathology after biomedical transitioning has been completed to the satisfaction of patients (Dhejne et al., 2011).

Another difficulty in discerning the legitimacy of medicalization for those trans people relying on healthcare to resolve their distress is that there is heterogeneity of viewpoints from clinicians working in this field. Some retain a biomedical view of transitioning, aligned with an everyday assumption of heteronormativity. Others though hold a more flexible social model that respects diverse forms of self-identification, case by case. This legitimizes such patient options as being “a woman with a penis,” who may self-define as a lesbian.

The heterogeneity of these clinicians’ views has been explored in Portugal by Hilário (2019). In the UK, divisions about what services are actually doing for patients came to light when many left NHS gender services and some anonymously reported their concerns about the lack of psycho-social sophistication of a routine gender-affirmative approach (Gilligan, 2019). Likewise dissenting clinicians have expressed similar public concerns about their work in Sweden and the Netherlands (Mattisson and Jemsby, 2019; Tangelder, 2018).

Moreover, research linked to this ambivalence of clinicians is also characterized by ambiguity. According to different protagonists in the controversy, being trans might be one way of dealing with being gay or it could be about subtle aspects of neurodevelopment, or it could be about self-eroticization (“autogynephilia”) (Blanchard, 2005). The neurodevelopmental hypothesis links to the controversial prospect of male and female brains being ontologically different (Baron-Cohen, 2003; Brizendine, 2006; cf. Fine, 2010). If this is true then it might inflect the emotional and cognitive dispositions of children, with the possibility that the trans individual has a sense of being in the “wrong body” because their brain development is not typical of their natal sex.

Extending this point about potential biological determinism, another possibility is that trans experiences and desires are potentially connected to intersex phenomena. For now though most trans individuals are unremarkable genetically and physiologically at birth, compared to babies identified as intersex. Transgender individuals typically are part of the 99.9%+ of the mammalian population that is sexually dimorphic and so they are not intersex (Delimata, 2019). Thus the potential but unproven link between trans phenomena and intersex is controversial, with some intersex advocates resenting their cooption into trans ideology.

Recent evidence that more girls than boys now are asserting a trans identity might suggest that we are observing a social-psychological, not a bio-deterministic, process at work in relation to referral patterns to gender clinics. An expansion in rates of referral, and a switch from boys to girls predominating within them, has been recorded in the past decade (Kaltiala-Heino et al., 2015). A genetic or congenital mechanism should lead to a low and consistent incidence of referrals to medical services, so social contagion seems to be the strongest explanatory candidate (Littman, 2018; Marchiano, 2017).

A clinical presentation of an identified trans child might imply the need for a broader systemic understanding of their lives in both their schooling and family contexts, case by case, rather than a point diagnosis of gender dysphoria. However, such cautions have led themselves to controversy. For example, a Canadian clinical psychologist, Ken Zucker, who was not an opponent of pediatric transition for all cases, had his Ontario gender identity service closed down in 2015, after hostile lobbying from trans activists. The latter claimed that Zucker’s more cautious and watchful biopsychosocial approach was a form of “conversion therapy,” akin to that applied to homosexuals (cf. Zucker et al., 2012). This event emerged despite the original Dutch model (now expanded incautiously in some countries) actually being aligned with Zucker’s approach.

The natural world

At least some of the tension in the trans controversy relates to the meaning of our bodies (according to ourselves and others), especially in relation to the degree to which our genotypes might be altered by medical interventions. The future legitimacy of these phenotypical alterations, include potential alterations in age and race, not just sex, but also by becoming “trans-humans” as cyborgs. This wider “trans” question will be shaped by both social norms (see below) and human technological capability. The prospect of a transwoman bearing a child was rehearsed above. Transmen can already complete this act of sexual reproduction under medical management. Whilst intersex is the exception that proves the rule about sexual dimorphism in mammals, set in chain by evolution, it may be that in the future biological rather than social science will reveal the origins of transgenderism and its stronger form (transsexualism). Currently, this prospect is being debated but with no clear scientific answer to resolve the matter (Fine, 2010; cf. Smith et al., 2015).

Relationality

This plane has relevance for the future of trans people, given their statistical scarcity, implicating both intimate relationships and all of our shared everyday life. At least some of the current controversy focuses upon how the loneliness of trans people and their social rejection might lead to psychological distress, with oppressive interpersonal events, including violence, amplifying the latter. Increased tolerance or non-judgmental personal recognition is then not just a human rights issue; it also has implications for mental health.

Another reason that relationality is important is that “self-identification” implies that the mere assertion of identity is the necessary and sufficient condition for it to be socially and even legally recognized. However, this assumption is unproven: self-assertions require social validation and acceptance. For example, personal accounts are typically rejected from those we encounter, if we consider the speaker to be lying or deluded; credulousness is a social transaction (Antaki, 1981). Some transgressive public performances have remained enduring taboos (e.g. most societies today this would apply to nudity, physical violence, or insanity). What is not clear, for now, is whether transgender performativity will establish a ubiquitous tolerance or indifference from others. The current loose alliance noted at the outset from the range of critics of trans-affirmative ideology suggests that this normative shift has not yet occurred.

Socio-economic structures

Given that morbidity entails normativity (inter alia health refers to the mental and physical capacity for role success and rule conformity), then the persistence or reform of norms in the future in different cultures is a consideration about the transgender debate. The legitimacy of gender self-definition outside of the healthcare system is being supported by many in Western democracies, persuaded by the claims of trans activists. The bio-medicalized route is being supported by healthcare bureaucracies (such as the NHS in the UK) as well as being boosted by the wider process of pharmaceuticalization (Pilgrim and Entwistle, 2020; Williams et al., 2011). In Britain this trajectory was disrupted in December 2020 by a judicial review, critical of the policy of puberty blocker availability to children in the NHS (Judiciary of England and Wales, 2020). At the time of writing this judicial review is subject to appeal.

In other countries there may be different normative trajectories. For example, because homosexuality is outlawed in Iran today, transsexualism has emerged as a medicalized form of policy permission; immorality is thus politically re-framed in this theocracy as a form of disease (Harper, 2015). In the more liberal Thailand, culturally a range of trans identities are socially accepted (including those of tom-dee and kathoey). These politically different countries may then encourage greater pharmaceutical and surgical solutions to challenges of gender-identity than elsewhere. However, though still an international center of surgical enterprise, in 2008 Thailand introduced more restrictive legal constraints on biomedical interventions, similar to those operating in Europe. There is also variability in ease of consumer access state by state across the USA. Thus, consumer power varies across time and place in relation to biomedical interventions and may do so in the future.

An economic consideration is the funding of trans activism by rich benefactors, though this at times can lead to a form of single factor causal reasoning (see, e.g. Bilek, 2020a, 2020b). A less reductionist analysis of financial backing is offered by Biggs (2018). He notes that whilst it is true that some super-rich people now provide multi-million dollar backing for trans activist organizations, it is not the amounts involved but the bias evident. For example, in 2017 the Open Society Foundations (OSF) supplied $3.07 million to trans activist organizations. For perspective, this was only 0.3% of the OSF funding for charitable causes that year. The critical point noted for Biggs was that there is no record of the OSF providing any money at all for gender critical organizations. “Big philanthropy” for now seems to be supporting only one side in this particular domain of the “culture wars.” Biggs outlines the same funding bias in the case of other multi-million dollar benefactors, such as the Arcus Foundation and the Tawani Foundation.

From a CR perspective, we would expect complexity about any aspect of social ontology (not just trans activism). Accordingly, Bilek’s reductionist assertions need to be considered with that caution in mind and the moderating, though still critical, perspective offered by Biggs. Other contextualising considerations, noted earlier, are pharmaceuticalization, professional interest work, and the overarching and expansive logic of identity politics. The latter, which more generally hyper-valorizes subjectivity, stimulates political claims based upon self-identification. Thus, the ideology of sacralized subjectivity, drives bids for citizenship from activists. This ideological dynamic, not just objective economic factors, needs be part of any sociological formulation about the emergence of particular NSMs, including trans activism.

The trans debate reflects a wider tension between the emphases of identity politics and those of the older tradition of political economy and the reforms they implied. These two forms of judgment might be aligned in our appraisals of social progress, but they may be incommensurable. The lack of mutual respect within competing versions of identity politics has created a blocked dialectic, with one set of repeated assertions on one side from trans activists (e.g. “a transwoman is a woman”) being met with another set on the other from some feminists (e.g. “a woman is an adult human female”).

What remains unclear at present is whether the blocked dialectic will move on to a clearer consensus position about what might constitute social progress about biological sex and gender identity. Moreover, if so, how might that resolution proceed and with what metaphysical justification? Intersectionality as a site of social ontology containing complex generative mechanisms (n.b. not just variegated identities) might be a point of conflict resolution. Some critical realists have explored the conditions for establishing such a dialog but for now these are only suggestive and not evidence of concrete success (e.g. Dy, 2020; Gunnarsson, 2013; Hull, 2008; New, 2005; Pilgrim, 2018; Summersell, 2018).

Individual personalities

It is at the level of our concrete singularities that psychological differences (in this case about our experience of the “fit” between our natal bodies and our sense of who we are) is the starting point for any current or future discussion of trans phenomena. However, this experiential starting point soon is tested out in the other three planes. Can or should the discomforted person seek an answer to their existential predicament in biomedical solutions or in the civil rights demand that others should accept them as being say a woman, when phenotypically they are seen as a man? Will those around them welcome and tolerate these existential struggles and their preferred solutions or will they oppose them in a range of ways? Will social and economic conditions shape what can be experienced and what cannot?

How these questions are worked through in healthcare settings, depends for now on the wider blocked dialect noted above. Individual trans identities might be instated in public policy as being merely variations in human experience (the position of trans affirmative activism opposed to medicalization) deserving of respect at all times. Alternatively, they may be resisted for a range of overlapping, though not identical, reasons from religious conservatives, gender critical feminists, and metaphysical realists. These “cis” social actors are also individual personalities with their particular axiological priorities. They are not at all persuaded that the expectation of an epistemological privilege from trans affirmative activists should be readily accepted and automatically determine public policy.

If comprehensive de-medicalization were to prevail, then the personal challenges of trans individuals will be removed altogether from the domain of healthcare and its authoritative clinicians, leaving the historical legacy of transsexualism in limbo. If, on the other hand, the current trend of medicalization continues then the cognitive interests of clinical professionals (mental health workers, surgeons, and endocrinologists), as well as the commercial interests of the drug and medical technology companies, will be maintained and are likely to be enhanced.