Gender-affirming care – the approach of affirming a person’s self-defined gender identity and changing the appearance of the body to align with this identity – is essentially the only response to gender dysphoria. So, this treatment, these puberty blockers, cross-sex hormones, and surgical transitions, must have a solid track record of success, right?
Unfortunately, no. There are no studies that compare the health outcomes of children and adolescents who receive gender-affirming care with those whose gender dysphoria resolved after puberty without medical or surgical intervention. We’ll repeat that. There are no studies that compare the health outcomes of children and adolescents who receive gender-affirming care with those whose gender dysphoria resolved after puberty without medical or surgical intervention.
The reason where there are no studies comparing whether watchful waiting or gender-affirming care is the better response to gender dysphoria is primarily because researchers have considered it unethical to randomly selecting some patients for medical transition and some patients for a wait and see approach.1 Such a random assignment is critically important to determine cause and effect and to generalize results to a broader population. Researchers have devised other ways to design studies to measure the impact of gender-affirming care on patients, but none of them are of high quality or high confidence.2
There are no studies that compare the health outcomes of children and adolescents who receive gender-affirming care with those whose gender dysphoria resolved after puberty without medical or surgical intervention.
In other words, there is no gold-standard evidence that receiving remarkably invasive and irreversible gender-affirming care leads to better outcomes than interventions that actively decrease cross-gender identification or watchfully wait for gender dysphoria to subside.3
In fact, there is lots of evidence that suggests that gender-affirming care is actually harmful.
Let’s start with puberty blockers. Puberty blockers are often compared to hitting the pause button on puberty to allow time for a child to explore their gender identity. But endocrinologist William Malone describes how, after a while, “the [endocrine] system ‘goes to sleep’ and at some point it may not wake up.”4 Abigail Shrier notes, “we wouldn’t consider a drug that stunted your growth in height and weight to be a psychologically neutral intervention – because it isn’t one… and yet the change in height brought on by growth hormones is arguably far less profound than that caused by puberty’s years-long flood of hormones, which transform our bodies into sexual adults.”5 Another concern is that one of the drugs commonly used to block puberty, Lupron, is the same drug was used to chemically castrate sex offenders. It is approved to treat symptoms of prostate cancer, endometriosis, and precocious puberty but is used “off-label” in a medical transition.
“We wouldn’t consider a drug that stunted your growth in height and weight to be a psychologically neutral intervention – because it isn’t…”
Common side effects of puberty blockers are redness/burning/stinging/pain/bruising at the injection site, hot flashes, increased sweating, night sweats, tiredness, headache, upset stomach, nausea, diarrhea, constipation, stomach pain, breast swelling or tenderness, acne, joint/muscle aches or pain, trouble sleeping (insomnia), reduced sexual interest, vaginal discomfort/dryness/itching/discharge, vaginal bleeding, swelling of the ankles/feet, increased urination at night, dizziness, breakthrough bleeding in a female child during the first 2 months of leuprolide treatment, weakness, chills, clammy skin, skin redness, itching or scaling, testicle pain, impotence, depression, increased growth of facial hair, and memory problems.6
And then there is cross-sex hormones. The risks from cross-sex hormones are even more serious, and include venous thromboembolism (blood clots), hyperkalemia (high potassium), hypertriglyceridemia (high level of fats in blood), polycythemia (high red blood cell count), hyperprolactinemia (high prolactin hormone levels), decreased HCL cholesterol and increased LDL cholesterol, hypertension (high blood pressure), cardiovascular disease, cerebrovascular disease, meningioma (brain tumor), polyuria (excessive urine production), dehydration, cholelithiasis (gallstones), type 2 diabetes, low bone mass, osteoporosis, weight gain, acne, sleep apnea, androgenic alopecia (hair loss), erectile dysfunction, and infertility.7
And this is just the list of possible effects of hormonal treatment. Surgical interventions can bring a host of new adverse effects, depending on the type of surgery. For example, there are numerous reports of hair painfully growing within the neo-vaginal lining follow a vaginoplasty, urination complications following a phalloplasty, and even fatal sepsis following a mastectomy. Most forms of bottoms surgery are guaranteed to lead to infertility: how can someone father a child if their testicles have been removed or conceive a baby of their uterus is gone?
Those are the risks for what is supposed to be gender-affirming care. But are there any benefits?
While some studies document improved mental health outcomes after hormonal or surgical interventions,8 these studies only report on short-term outcomes. Much more valuable studies, known as longitudinal studies, track outcomes over long periods of time. The best longitudinal study, headed by Swedish researcher Cecilia Dhejne, found that health outcomes deteriorate just one year after undergoing a surgical transiti
poorer outcomes in seven of eight measured categories: mental health, vitality, bodily pain, social function, emotional functioning, physical functioning, and general health.9
“Gender-affirming care” is a misnomer. It’s not caring at all.
These are only some of the harms of medical gender transitioning. And this is why “gender-affirming care” is a misnomer. It’s not caring at all. It ignores our biological identity as a male or a female, and so perhaps it isn’t all that surprising that there are all of these negative effects of medical or surgical transitioning.
So, what counts as success when treating gender dysphoria? All sides in this debate should agree that, at a minimum, the loss of fertility and increased risk of a host of serious medical conditions, are not signs of success. Yet, these are the results of medical transitioning far too often.
Defining success as improved life satisfaction and decreased risk of suicidality and self-harm is a good step in the right direction, but even on this score, the long-term data on these measures of success do not favour medical transitioning.
See Michelle A Cretella, “Gender Dysphoria in Children and Suppression of Debate” 21, no. 2 (2016). ↩︎
See Society for Evidence-Based Gender Medicine, “International Perspectives on Evidence-Based Treatment for Gender-Dysphoric Youth Conference,” October 10-11, 2023, New York ↩︎
See Yarhouse, Understanding Gender Dysphoria, 102–3. for a description of these approaches ↩︎
Talal Alzahrani et al., “Cardiovascular Disease Risk Factors and Myocardial Infarction in the Transgender Population,” Circulation: Cardiovascular Quality and Outcomes 12, no. 4 (April 2019): e005597, https://doi.org/10.1161/CIRCOUTCOMES.119.005597; Michael S. Irwig, “Cardiovascular Health in Transgender People,” Reviews in Endocrine and Metabolic Disorders 19, no. 3 (September 1, 2018): 243–51, https://doi.org/10.1007/s11154-018-9454-3; Stephen M. Rosenthal, “Challenges in the Care of Transgender and Gender-Diverse Youth: An Endocrinologist’s View,” Nature Reviews Endocrinology 17, no. 10 (October 2021): 581–91, https://doi.org/10.1038/s41574-021-00535-9; Silvano Bertelloni et al., “Final Height, Gonadal Function and Bone Mineral Density of Adolescent Males with Central Precocious Puberty after Therapy with Gonadotropin-Releasing Hormone Analogues,” European Journal of Pediatrics 159, no. 5 (April 1, 2000): 369–74, https://doi.org/10.1007/s004310051289; Ana Antun et al., “Longitudinal Changes in Hematologic Parameters Among Transgender People Receiving Hormone Therapy,” Journal of the Endocrine Society 4, no. 11 (November 1, 2020): bvaa119, https://doi.org/10.1210/jendso/bvaa119; Hayley Braun et al., “Moderate-to-Severe Acne and Mental Health Symptoms in Transmasculine Persons Who Have Received Testosterone,” JAMA Dermatology 157, no. 3 (March 1, 2021): 344–46, https://doi.org/10.1001/jamadermatol.2020.5353; Mauro E. Kerckhof et al., “Prevalence of Sexual Dysfunctions in Transgender Persons: Results from the ENIGI Follow-Up Study,” The Journal of Sexual Medicine 16, no. 12 (December 1, 2019): 2018–29, https://doi.org/10.1016/j.jsxm.2019.09.003; Spyridoula Maraka et al., “Sex Steroids and Cardiovascular Outcomes in Transgender Individuals: A Systematic Review and Meta-Analysis,” The Journal of Clinical Endocrinology & Metabolism 102, no. 11 (November 1, 2017): 3914–23, https://doi.org/10.1210/jc.2017-01643; M. Kyinn et al., “Weight Gain and Obesity Rates in Transgender and Gender-Diverse Adults before and during Hormone Therapy,” International Journal of Obesity 45, no. 12 (December 2021): 2562–69, https://doi.org/10.1038/s41366-021-00935-x; Sebastian E E Schagen et al., “Bone Development in Transgender Adolescents Treated With GnRH Analogues and Subsequent Gender-Affirming Hormones,” The Journal of Clinical Endocrinology & Metabolism 105, no. 12 (December 1, 2020): e4252–63, https://doi.org/10.1210/clinem/dgaa604; Daniel Klink et al., “Bone Mass in Young Adulthood Following Gonadotropin-Releasing Hormone Analog Treatment and Cross-Sex Hormone Treatment in Adolescents With Gender Dysphoria,” The Journal of Clinical Endocrinology & Metabolism 100, no. 2 (February 1, 2015): E270–75, https://doi.org/10.1210/jc.2014-2439; Magdalena Dobrolińska et al., “Bone Mineral Density in Transgender Individuals After Gonadectomy and Long-Term Gender-Affirming Hormonal Treatment,” The Journal of Sexual Medicine 16, no. 9 (September 1, 2019): 1469–77, https://doi.org/10.1016/j.jsxm.2019.06.006; Darios Getahun et al., “Cross-Sex Hormones and Acute Cardiovascular Events in Transgender Persons,” Annals of Internal Medicine 169, no. 4 (August 21, 2018): 205–13, https://doi.org/10.7326/M17-2785; Mariska C. Vlot et al., “Effect of Pubertal Suppression and Cross-Sex Hormone Therapy on Bone Turnover Markers and Bone Mineral Apparent Density (BMAD) in Transgender Adolescents,” Bone 95 (February 1, 2017): 11–19, https://doi.org/10.1016/j.bone.2016.11.008; Iris E. Stoffers, Martine C. de Vries, and Sabine E. Hannema, “Physical Changes, Laboratory Parameters, and Bone Mineral Density During Testosterone Treatment in Adolescents with Gender Dysphoria,” The Journal of Sexual Medicine 16, no. 9 (September 1, 2019): 1459–68, https://doi.org/10.1016/j.jsxm.2019.06.014; Michael Biggs, “Revisiting the Effect of GnRH Analogue Treatment on Bone Mineral Density in Young Adolescents with Gender Dysphoria,” Journal of Pediatric Endocrinology and Metabolism 34, no. 7 (July 1, 2021): 937–39, https://doi.org/10.1515/jpem-2021-0180; Rafael Delgado-Ruiz, Patricia Swanson, and Georgios Romanos, “Systematic Review of the Long-Term Effects of Transgender Hormone Therapy on Bone Markers and Bone Mineral Density and Their Potential Effects in Implant Therapy,” Journal of Clinical Medicine 8, no. 6 (June 2019): 784, https://doi.org/10.3390/jcm8060784; Tobin Joseph, Joanna Ting, and Gary Butler, “The Effect of GnRH Analogue Treatment on Bone Mineral Density in Young Adolescents with Gender Dysphoria: Findings from a Large National Cohort,” Journal of Pediatric Endocrinology and Metabolism 32, no. 10 (October 1, 2019): 1077–81, https://doi.org/10.1515/jpem-2019-0046; Kyinn et al., “Weight Gain and Obesity Rates in Transgender and Gender-Diverse Adults before and during Hormone Therapy”; Noreen Islam et al., “Is There a Link Between Hormone Use and Diabetes Incidence in Transgender People? Data From the STRONG Cohort,” The Journal of Clinical Endocrinology & Metabolism 107, no. 4 (April 1, 2022): e1549–57, https://doi.org/10.1210/clinem/dgab832. ↩︎
See Coleman et al., “Standards of Care for the Health of Transgender and Gender Diverse People, Version 8.” for a sample of studies ↩︎
Cecilia Dhejne et al., “Long-Term Follow-Up of Transsexual Persons Undergoing Sex Reassignment Surgery: Cohort Study in Sweden,” PLOS ONE 6, no. 2 (February 22, 2011): e16885, https://doi.org/10.1371/journal.pone.0016885. ↩︎
Most people’s gender identity – their self-perception of being male or female – aligns with their biological sex. According to the 2021 census, 99.7% of Canadians aged 15 years and older affirm that their internalized gender identity matches their biological sex (Statistics Canada). A small minority of people – the remaining 0.33% of Canadians – experience gender dysphoria.
Gender dysphoria is a condition in which a person’s gender identity does not match their sex (see note). For example, someone who is a biological female may feel that she is, or should be, male. Gender dysphoria, a psychological phenomenon, is not to be confused with biological disorders of sexual development, which are even more rare.
While there is no single, generally accepted cause for gender dysphoria, there are discernible trends among children and adolescents with gender dysphoria. Among children who exhibit gender dysphoria prior to puberty, approximately 80% will “desist” or out-grow this dysphoria by adulthood.* However, the number of post-pubescent adolescents – teenage girls in particular – with gender dysphoria has skyrocketed in western countries like Canada, the United States, and the United Kingdom in recent years. Researchers have called this phenomenon rapid-onset gender dysphoria and some suggest that it is a social contagion.**
Among children who exhibit gender dysphoria prior to puberty, approximately 80% will “desist” or out-grow this dysphoria by adulthood.
The current Canadian approach to treating gender dysphoria is called, euphemistically, gender-affirming care. This approach to care is described in the World Professional Association on Transgender Health (WPATH)’s Standards of Care. Canadian provinces generally follow these WPATH standards, albeit with significant differences between provinces. Regulatory colleges recommend or require this approach. Under this approach, when a child or adolescent reaches out to a health practitioner about gender dysphoria, the practitioner affirms the patient’s self-perceived gender identity and seeks to change the patient’s body to appear more like the desired sex.
In other words, unlike in other areas of medicine, gender clinicians typically agree with patients’ (or, in the case of young children, their parents’) self-diagnosis of gender dysphoria and refer for treatment on the basis of this self-diagnosis. The clinician doesn’t perform any tests to diagnose gender dysphoria. The clinician can’t encourage a child to think of themselves or act in a way that corresponds with their birth sex – that’s illegal under Canada’s ban on conversion therapy. Under the paradigm of gender-affirming care, there is only one acceptable treatment direction: onward to a medical and/or surgical transition.
According to WPATH’s standards, medical practitioners should only proceed to gender-affirming medical and surgical treatment for minors if:
Gender dysphoria is marked and sustained over time;
The diagnostic criteria of gender dysphoria are met (as per International Classification of Diseases 11)11;
The patient demonstrates the emotional and cognitive maturity required to provide informed consent;
Mental health concerns (if any) have been addressed;
The patient has been informed of the effects of treatment on reproduction;
The patient has reached Tanner stage 2 of puberty (the beginning of the physical stages of puberty) for puberty blockers and cross-sex hormones; and
The patient has received at least 12 months of gender-affirming hormone therapy (before gender reassignment surgery can be performed).***
The fundamental problem with gender-affirming care is that it misdiagnoses the problem. Gender dysphoria is not a problem of the body. While gender identity and gender expression can change over the course of someone’s lifetime, biological sex cannot change.
“The fundamental problem with gender-affirming care is that it misdiagnoses the problem.”
True, hormone injections can trigger the development of secondary sex characteristics (e.g. facial hair, lower voice, or an Adam’s apple). And surgical procedures can remove or create imitations of reproductive organs. However, hormones and surgeries cannot change the fundamental sexual organization of the human body as male or female.
A person’s sex is objectively determined by the organization of their body for a specific reproductive role – to produce sperm cells (male gametes) or egg cells (female gametes), as evidenced by the person’s sex chromosomes, naturally occurring sex hormones, and internal and external genitalia. Aside from extremely rare genetic disorders, each cell in a person’s body has either an XY chromosome (male) or an XX chromosome (female). In short, while these gender transition surgeries are often called “sex change surgeries,” such a term is a misnomer because it’s impossible to change your biological sex.
Gender-affirming care assumes that the fundamental problem is that a person is born into the wrong body. By getting the problem wrong, it also gets the solution wrong. Its misguided solution to gender dysphoria is to radically reshape the body, at great cost to physical health (more on that in a future post).
“The solution is not to radically reshape the body through drugs, hormones, and surgery. The solution is to help someone accept and love their natural body. ”
The problem of gender dysphoria does not lie with the body. It lies with the mind. Those who experience gender dysphoria have nothing wrong with their body. Rather, they have difficulty identifying with or accepting their body. That is a real and very difficult struggle. But the solution is not to radically reshape the body through drugs, hormones, and surgery. The solution is to help someone accept and love their natural body.
In a review of Johns Hopkins University’s “sex change” clinic, former director Dr. Paul McHugh states that “in a thousand subtle ways, the re-assignee has the bitter experience that he is not — and never will be — a real girl but is, at best, a convincing simulated female. Such an adjustment cannot compensate for the tragedy of having lost all chance to be male, and of having in the final analysis, no way to be really female.”1
Dr. Sander Breiner agrees, explaining that she and her colleagues at Michigan’s Wayne State University had to tell the surgeons that “the disturbed body image was not an organic [problem] at all, but was strictly a psychological problem. It could not be solved by organic manipulation (surgery, hormones).”2
It is common today for people to speak of being a woman trapped in a man’s body or a man trapped in a woman’s body. But, as Toronto psychiatrist Dr. Joseph Berger explains, “scientifically, there is no such thing.”3
There are a variety of words used to describe this phenomenon. ARPA Canada prefers the term “gender dysphoria,” found in the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders V. The International Classification of diseases uses “gender incongruence,” WPATH prefers the term “transgender and gender diverse people,” while the vernacular defaults to the descriptor “transgender.”
*** Coleman et al., “Standards of Care for the Health of Transgender and Gender Diverse People, Version 8,” 18.
1. Dr. Paul McHugh is Distinguished Service Professor of Psychiatry at Johns Hopkins University. In 2004, Dr. McHugh published an article explaining the scientific reasons for rejecting sex change procedures. After describing the great deal of damage he witnessed from sex-reassignment, he concluded, “we psychiatrists have been distracted from studying the causes and natures of their mental misdirections by preparing them… for a life in the other sex. We have wasted scientific and technical resources and damaged our professional credibility by collaborating with madness rather than trying to study, cure, and ultimately prevent it.” Paul R. McHugh, “Surgical Sex: Why We Stopped Doing Sex Change Operations” (Nov. 2004) First Things.
3. Written testimony of Dr. Joseph Berger to the House of Commons Standing Committee on Justice and Human Rights, regarding Bill C-279.
In the first policy of its kind in Canada, Alberta will be limiting medical transitioning for minors.
Until now, there has been no legislation, regulation, or official policy about when minors can access puberty blockers, cross sex hormones, or transition-related surgery. Many countries around the world (such as Finland, Sweden, the United Kingdom, and France) as well as 22 American states have already limited medical transitioning for minors. Canadian provinces held doggedly to the deeply flawed World Professional Association on Transgender Health (WPATH)’s standards of care, which list no age restriction for medical transitioning.
That changed when Alberta Premier Danielle Smith made a suite of announcements relating to transgender policy.
The most important policy change is that puberty blockers and cross-sex hormones will be banned for those aged 15 and under. For youth aged 16 or 17, parental, physician, and psychologist approval will be required to begin a medical transition.
There is no comprehensive data available on the number of minors receiving puberty blockers and cross-sex hormones across Canada. But considering that most puberty blockers are prescribed near the onset of puberty, this policy will likely prevent many children from starting on the medical transition conveyor belt at an early age and going on to receive cross-sex hormones and surgery.
This is good for children. There is little evidence on the long-term safety of puberty blockers, and there are many documented risk factors associated with cross-sex hormones, including blood clots, heart disease, cerebrovascular disease, brain tumors, and osteoporosis.
Top surgeries (mastectomies) and bottom surgeries (phalloplasties, vaginoplasties, and metoidioplasties) will be banned for minors aged 17 and under in Alberta. According to information released by the Canadian Institute for Health Information (CIHI), while there are very few bottom surgeries performed on minors in Canada, there are dozens of minors having mastectomies every year.
The message from the Alberta premier is clear: children do not have the capacity to make these profound decisions about their bodies.
Regardless of how many damaging prescriptions or procedures these new rules prevent, the message from the Alberta premier is clear: children do not have the capacity to make these profound decisions about their bodies. The Alberta health system will no longer be party to these procedures for minors aged 15 years and below.
Premier Smith applied the same logic to school settings. Following the lead of New Brunswick and Saskatchewan, Alberta will require parental notification and consent if a child aged 15 or under wishes to change their name or pronouns at school. For minors aged 16 or 17, parental notification for name or pronoun changes will still be required. Seventy-eight percent of Canadians and 88% of Albertans favour this policy change, as measured in an Angus Reid poll last July.
Alberta will also require teachers to notify parents before giving formal instruction on gender, sexual orientation or human sexuality in the classroom. Parents must actively opt into their children receiving such instruction. This is a significant change from the previous policy, where teaching about sexual orientation and gender identity (SOGI 123) was adopted by school districts across the province and embedded throughout the curriculum.
Finally, the Alberta government committed to work with sporting organizations to ensure that biological women and girls have the choice to compete in athletic competitions in a women-only division without any trans-identifying males. This policy recognizes that men and women, boys and girls have fundamentally different bodies with different performance capabilities.
These developments – particularly the age restrictions for medical transitioning – are enormous.
These developments – particularly the age restrictions for medical transitioning – are enormous. Countries and states around the world that have taken time to review the evidence in favour of medical transitioning have found it lacking and, in the interest of protecting the health of children, have limited medical transitioning for minors. It is not only appropriate but morally responsible of Alberta to limit these procedures. We call on other Canadian provinces to follow Alberta’s lead and end medical transitioning for minors.
Childhood is a precious time that should be protected. We need to let kids be – let them grow and develop naturally. Children who suffer from gender dysphoria have an identity struggle. But there is nothing medically wrong with their bodies, and it is entirely inappropriate to medically or surgically alter children’s bodies to solve an identity crisis. In fact, over 80% of cases of pre-pubescent gender dysphoria go away after puberty. Medical transitioning not only is unnecessary, but harmful. Instead, we simply need to let kids be.
Not long ago, people used both sex and gender to describe the reality that human beings are biologically male and female. But today, these words mean different things. They are now used to distinguish between biological function and social function. While sex refers to the biological reality of being male or female (defined by chromosomes and various primary and secondary sex characteristics), language has shifted so that gender now refers to perceived psychological, social, and cultural aspects of being male or female.
Despite the cultural change, gender differences remain rooted in sex differences. While there remains great diversity within men as a group or women as a group, biological differences do contribute to psychological and personality differences between men and women on average. These differences contribute to different levels of interest and participation in certain occupations, sports, and recreational activities. Such differences are natural, not nefarious. In progressive countries with policies promoting sexual equality and with many career paths open to both sexes, differences in men’s and women’s occupational preferences often become more, not less, pronounced.
That is not to say that all cultural expectations related to gender or all differences of participation in certain occupations or activities are right or fair. But accepting and appreciating that there is a natural connection between sex differences and gender differences is essential for preserving mental and emotional well-being. Gender differences are not inherently bad. We should be careful about trying to eliminate any and all gender differences to create uni-sex or uni-gender human beings. Like uni-corns, they don’t and, more fundamentally, can’t exist.
“Accepting and appreciating that there is a natural connection between sex differences and gender differences is essential for preserving mental and emotional well-being.”
We should also be careful not to strictly enforce assumed gender differences, which may artificially limit people in developing their gifts and interests. Telling a boy who enjoys activities typically associated with the opposite sex that he should not do those things because he is a boy may cause him needless distress and confusion about his identity.
Early feminists rightly highlighted both the differences between and the fundamental equality of men and women. Treatises by early modern feminists spoke of the equality of the sexes (rather than genders) in their writing (see, for example, Simone De Beauvoir, The Second Sex, 1949.) However, the focus of gender discussions is now gender identity, a concept that overrides and even erases sex.
(Photograph by Andrea Piacquadio / Pexels.com)
Gender identity is a relatively new concept. It is not the same as gender. Whereas gender refers to the social and cultural aspects of being male or female, gender identity refers to one’s internal, subjective sense of being male or female. Thus, in the past, a boy who wore a dress and make-up to look like a girl might have been called a “boy presenting as a girl.” But today, a boy who believes he is “truly” a girl but who does not try to appear to be female would still be considered a girl presenting as a boy.
Gender expression is another new term. It refers to the way in which a person attempts to express his or her gender identity through clothing, cosmetics, and mannerisms. Ironically, this expression usually depends on gender stereotypes or social constructs (e.g. that pink is a feminine colour or that short hair is a masculine feature).
“Biological sex, gender, and gender identity are all connected, not separate.”
Gender ideology today claims that a person’s “true” identity as male or female (or both, neither, or somewhere in between) depends on his or her self-conception, not on his or her biological body. People rarely ask what it means, for example, for a boy to “feel” or “know” he is girl. He might desire to be girl, or imagine what it would be like to girl, or even mistakenly believe he really is girl. But none of these would make him a girl. The explanation given when it comes to identifying young children as transgender is often shockingly shallow, such as noting that a boy prefers (stereotypically) feminine toys, colours, and clothes.
Biological sex, gender, and gender identity are all connected, not separate. They are not like Lego pieces that can be assembled in an infinite combination of patterns. They are more like the roots, the trunk, and the leaves of a tree that are organically connected to each other and support one another. That is the way that human beings best flourish, and the reason we advocate against cultural efforts to break sex, gender, and gender identity apart.
Welcome to the Let Kids Be community! This campaign aims to protect children and adolescents from making irreversible decisions about their bodies at too young an age. There is a huge (and growing) number of arguments and lines of evidence to support a ban on medical transitioning for minors. Our goal with this blog is to pass along this information in an accessible way that you can use in your advocacy to protect young people.
To start, we need to go all the way to the mislaid foundations that led to medical transitioning for minors becoming an accepted practice. Then we need to lay a better foundation for how our society should approach conversations about gender, gender identity, and gender expression.
The foundations start with anthropology – that is, the study of human beings. If we get our anthropology wrong, we’ll likely come to the wrong conclusions and the wrong solutions to a variety of problems. But if we get our anthropology right, we have a much better foundation to build upon.
So, what are human beings, anyways?
A very basic truth about human anthropology is that every human being is biologically male or female. Sexuality and sexual development begin with genetics. From the moment of fertilization, every human being is designed to develop either as a male (primarily determined by the presence of a Y chromosome) or as a female (primarily determined by the absence of a Y chromosome). As the cells of a zygote divide and multiply, each cell in that human body bears the chromosomal markers of the person’s sex. Throughout a person’s entire lifespan, those genetic markers remain the same. They are fixed. Sex is not “assigned” at birth only to evolve over the course of one’s lifetime. It is genetically determined at conception and, in nearly all cases, easily recognized at birth or even in utero. Disorders of sexual development are rare and are referred to as disorders because they are inconsistent with the natural sexual binary.
Throughout our lives, our sexual development continues with hormones. As a human body develops in utero and through puberty, our chromosomes play a dominant role in the production of sex hormones. While estrogen and testosterone are both present in males and females, greater levels of testosterone are present in males and greater levels of estrogen are present in females. These hormones become especially important during puberty when they spur the development of reproductive systems.
The human reproductive systems are generally considered in biology to be the key differentiators between males and females. Males have the capacity to produce sperm and females the ability to produce eggs and bear young. The complementary male and female reproductive systems are designed to work together to create new human beings.
Sexual development and differentiation include differences in appearance aside from primary sex characteristics. Secondary sex characteristics in males include more facial hair, relatively thick and dark body hair, thicker and tighter skin, a deeper voice, a larger face, a more prominent brow, nose, and chin, and an Adam’s apple. Females are characterized by relatively sparse and light body hair, a smaller face, a higher pitched voice, and the presence of breasts. People are able to identify an adult’s sex with an incredible degree of accuracy merely by observing his or her face.2
Although the differences in secondary sex characteristics are the most visible aspect of our sexual differentiation, sex is not reducible to sex characteristics. Sexual differences extend beyond genetic sex, sex hormone levels, reproductive capacity, or primary or secondary sex characteristics, most of which are categorical differences. A burgeoning body of literature reveals other statistical differences between the sexes, including the percentage of muscle mass and fat tissue, hearing ability, susceptibility to diseases, learning styles, and patterns of brain activity.*
These statistical sex differences can be illustrated by overlapping bell curves. For example, males will, on average, be taller and physically stronger than women, though there are some women who are taller and stronger than some men. The consequences of these strength and size differences are obvious. For example, they account for the statistical differences in sport records, where all male sports have faster, stronger, or longer world records than those set by elite athletes in women’s sports.
Foundational sexual differences in the genetic code direct each person’s complex and marvelous path of growth and development into either a man or a woman. These biological differences are evident in different reproductive capacities, but also in many other ways. None of these differences make males or females unequal as persons. Rather, sexual difference is simply something to acknowledge as a fundamental part of who we are as human beings.
*V. Bruce et al., “Sex Discrimination: How Do We Tell the Difference between Male and Female Faces?,” Perception 22, no. 2 (1993): 131–52, https://doi.org/10.1068/p220131.