Gender reassignment of children. Does it really help?

"Flower boy" (on the right) - In 70-80% of cases, gender confusion will clear up on its own (Wikicommons: Recoplado).

 

I remember feeling some attraction to girls in Grade 2, but it really wasn't until Grade 8 that everything fell into place. I'm talking about puberty. Before high school, I was a boy and not a young man.

I didn't consider myself abnormal. Yes, many boys in Grade 8 had deeper voices, as well as signs of facial hair, but just as many did not, and a few would not have been "sexually functional." As for the earlier grades, certainly before Grade 7, most of us could have passed for little girls—just change the clothing, the hairstyle, and voilà!

Today, puberty is starting earlier. Ontario schools will begin explaining it in ... Grade 4. This falling age is largely due to the changing ethnic and racial origins of the student population, as well as things like overeating (in the case of girls) and perhaps our more sexualized culture.

Nonetheless, a lot of boys remain pre-pubertal throughout most of primary school, and some may have trouble coming to terms with their male identity. They experience what is called “gender confusion.” This is hardly surprising. Testosterone levels are low before puberty, and some boys, especially the ones who have been less androgenized in the womb, may genuinely feel like a girl. I also suspect that modern culture makes things worse by creating expectations that even adult males have trouble meeting. Go to any fitness center and you'll see plenty of young men trying to bring their bodies into line with the "rippled look."

Gender confusion, known medically as gender identity disorder, affects children of both sexes but boys much more so, at least in North America. One clinic reported a ratio of 6.6 boys for each girl, the sex imbalance being attributed partly to greater intolerance of feminine behavior in boys (Zucker et al., 1997). This disorder seems to be partly heritable, although we face a similar problem of perspective here as with the referral statistics (Heylens et al., 2012). To what degree does the heritable component reside in how these children objectively behave, and not in one behavior that may or may not alarm another person, usually a parent? In practice, it’s the latter. It’s whatever behavior that makes a parent bring the child to a clinician’s office.

Gender reassignment

We now come to the issue of medical treatment, specifically "gender reassignment." This treatment has recently been condemned by Dr. Paul McHugh, the former psychiatrist-in-chief for Johns Hopkins Hospital:

Then there is the subgroup of very young, often prepubescent children who notice distinct sex roles in the culture and, exploring how they fit in, begin imitating the opposite sex. Misguided doctors at medical centers including Boston's Children's Hospital have begun trying to treat this behavior by administering puberty-delaying hormones to render later sex-change surgeries less onerous—even though the drugs stunt the children's growth and risk causing sterility. (McHugh, 2015)

Is treatment really necessary? McHugh points out: "When children who reported transgender feelings were tracked without medical or surgical treatment at both Vanderbilt University and London's Portman Clinic, 70%-80% of them spontaneously lost those feelings."

McHugh has been accused by the transgender community of misrepresenting the facts:

McHugh also mischaracterizes the treatment of gender nonconforming children. As McHugh states, most gender nonconforming children do not identify as transgender in adulthood.  However, those who receive puberty blocking drugs do not do so until puberty, when trans identity is likely to persist. These drugs allow adolescents and their parents to work with doctors to achieve the best outcome. This approach was demonstrated to be successful in research in the Netherlands before being adopted widely in the U.S. (WPATH, 2015) 

The above text is disingenuous in two ways. First, puberty-blocking drugs are not administered until puberty for an obvious reason: they would be ineffective earlier. The decision to use them, however, is made at an earlier time and often much earlier. Second, these drugs keep hormonal levels from rising, thus maintaining the boy or girl in the same hormonal state and possibly in the same state of gender confusion. Logically, one should wait a few years to see what effect puberty might have.

Is the use of these drugs legitimate? We’re talking about a radical intervention in the normal process of maturation, and this intervention begins before the age of consent, i.e., 16 years of age in most Western countries. Moreover, the eventual gender reassignment will never be complete. Although it’s possible to turn a male into a semblance of a female, such a “female” can never bear children. This isn’t a minor point, given that many male transsexuals wish to maintain a male heterosexual orientation, even to the point of marrying and becoming fathers.

For all these reasons, use of these drugs should be delayed until adulthood, when consent becomes morally defendable, when the risks of sterility are lower, and when the gender confusion may prove to be transitory.

A boy is not a little man

The transgender community likes to talk a good talk about "gender fluidity." Ironically, such fluidity is reduced by gender reassignment, which imposes a relatively unchanging adult dichotomy on pre-pubertal individuals who are going through rapid physical and psychological change. This brings us to a second irony. The transgender community complains about how it was once medically pathologized. Yet here it is pathologizing cases of gender confusion that are not unusual among young children and that are consistent with normal child development.

We should remember that both sexes begin with a body plan that is more female than male. This plan is modified at two points of the life cycle: first, in the womb, when the body’s tissues are primed by a surge of androgens or estrogens; and then at puberty, when boys and girls diverge in the levels of their circulating sex hormones, which in turn trigger profound changes in growth and development.

This truth was known to our ancestors. As late as the early 20th century, people accepted that little boys are more akin to little girls than to grown men. This was why both sexes would be dressed in female clothing until school age, and a mother would often boast that her little boy was as pretty as a girl.

[…] infants and small children had for hundreds of years been dressed alike, in frocks, so that family portraits from previous centuries made it difficult to tell the young boys from the girls. “Breeching,” as a rite of passage, was a sartorial definition of maleness and incipient adulthood, as, in later periods, was the all-important move from short pants to long. Gender differentiation grew increasingly desirable to parents as time went on. By the closing years of the twentieth century the sight of little boys in frilly dresses has become unusual and somewhat risible; a childhood photograph of macho author Ernest Hemingway, aged almost two, in a white dress and large hat festooned with flowers, was itself the focus of much amused critical commentary when reproduced in a best-selling biography—especially when it was disclosed that Hemingway’s mother had labelled the photograph of her son “summer girl.”  (Garber, 1997, pp. 1-2)

Hemingway hated those baby pictures, as well as the stories about how his mother would call him “Ernestine” and tell strangers that he and his sister were twin girls. During her declining years, he threatened to cut off his financial support if she ever gave an interview about his childhood (Onion, 2013; Winer, 2008). He saw her as the typical Victorian mother who sought to momify and symbolically castrate her male offspring. With other writers of his time, particularly psychologists and advice columnists, he helped bring about a reform of sexual conventions that, among other things, would sweep away the custom of cross-dressing little boys.

(see here for an early childhood photo of Hemingway and here for similar photos of H.P. Lovecraft

I remember how I felt seeing such photos when doing research on my family tree. What the?? Today, I feel differently: this cross-dressing strikes me as being healthy, even beautiful in its own way. It avoids the problem of imposing male identity too early in life and thereby forcing slower-developing boys to choose between the identity imposed by society and the one generated by their own mental state—which may still be insufficiently male. It is this situation, and the resulting gender confusion, that is now putting many boys at risk of gender reassignment. Yet there’s nothing wrong with most of them. They just need more time to grow up.

As an extreme example, let’s take the case of "pseudohermaphrodites"—males who look female at birth because their penis resembles a clitoris and because their testes remain inside the body. They are typically raised as girls until puberty, at which time the penis grows in size, the testes descend into the scrotum, and they become like men physically and psychologically. When 18 pseudohermaphrodites were studied in the Dominican Republic, it was found that 16 of them had made the transition from girlhood to manhood with no evidence of psychosexual maladjustment (Imperato-Mcginley et al., 1979). A similar situation often arose among Canada’s Inuit whenever a newborn received the name of a deceased relative. If the child was a boy and the relative a woman, it would be raised as a girl until puberty and as a man thereafter. Such individuals became not only husbands and fathers but also respected shamans (Saladin d'Anglure, 2005).

In short, gender confusion in childhood poses no threat to normal child development. Indeed, whether we acknowledge it or not, all boys start off being more like little girls than the men they will become. This “early girlhood” may actually play a key role in their psychosexual development, and our ancestors might have had good reasons to believe that boyhood begins later. But that raises a troubling question: by trying to masculinize this early phase of life, have we opened the door to unknown consequences?

So if you have a young boy who’s confused about his gender identity, the chances are very good that he’ll successfully transition to manhood ... as long as he’s not given puberty-blocking drugs. This is not a medical condition that needs treatment.

References 

Garber, M.B. (1997). Vested Interests: Cross-Dressing and Cultural Anxiety, Psychology Press.

https://books.google.ca/books?id=eeASHasS0oUC&printsec=frontcover&hl=fr&source=gbs_ge_summary_r&cad=0#v=onepage&q&f=false 

Heylens, G., G. De Cuypere, K.J. Zucker, C. Schelfaut, E.Elaut, H. Vanden Bossche, E. De Baere, and G. T’Sjoen. (2012). Gender identity disorder in twins: A review of the case report literature, The Journal of Sexual Medicine, 9, 751-757.

http://onlinelibrary.wiley.com/doi/10.1111/j.1743-6109.2011.02567.x/abstract 

Imperato-Mcginley, J., R.E. Petersen, T. Gautier, and E. Sturia. (1979). Male pseudohermaphroditism secondary to 5a-reductase deficiency—A model for the role of androgens in both the development of the male phenotype and the evolution of a male gender identity, Journal of Steroid Biochemistry, 11, 637-645.

http://www.sciencedirect.com/science/article/pii/0022473179900931 

McHugh, P. (2015). Transgender surgery isn't the solution, The Wall Street Journal, June 12

http://www.wsj.com/articles/paul-mchugh-transgender-surgery-isnt-the-solution-1402615120 

Onion, R. (2013). Pages from Hemingway’s baby books, Slate, July 23

http://www.slate.com/blogs/the_vault/2013/07/23/hemingway_scrapbooks_grace_hemingway_s_records_of_son_ernest_hemingway_s.html  

Saladin d'Anglure, B. (2005). The 'Third Gender' of the Inuit, Diogenes, 52, 134-144.

http://dio.sagepub.com/content/52/4/134.short 

Winer, A. (2008). Why Hemingway used to wear women’s clothing, Mental_floss, December 18

http://mentalfloss.com/article/20396/why-hemingway-used-wear-womens-clothing 

WPATH (2015). Wall Street Journal Editorial Critiques Transgender Health July 2, 2014

http://www.wpath.org/site_page.cfm?pk_association_webpage_menu=1635&pk_association_webpage=4905 

Zucker, K.J., S.J. Bradley, and M. Sanikhani. (1997). Sex differences in referral rates of children with gender identity disorder: some hypotheses, Journal of Abnormal Child Psychology, 25, 217-227.

http://link.springer.com/article/10.1023/A:1025748032640#page-1