When I read people talk about the etiology of transness– particularly, but not solely, discussion of the Blanchard/Bailey theory of trans women– I often see a response from cis people that’s along the lines of “Who cares? If you want to transition, I think you should transition. I don’t care whether it’s a fetish or caused by gender-non-conformity or whatever; as long as it makes you happy, it’s fine. You have the right to make decisions about your own body.”
To be clear, this is a really good attitude for people to have! In fact, I think it’s the correct attitude to have about other people’s transitions. It’s really none of your business what people decide to do with their own personal bodies: getting a tattoo, getting cosmetic surgery, not getting cosmetic surgery, or transitioning. Even if Anne Lawrence is a completely and 100% accurate reporter of her own internal experience, I support her right to transition.
But it also matters what’s true.
Even if information about the etiology of transness doesn’t (and shouldn’t!) affect the behavior of cis people, it sure as hell should affect the behavior of trans and gender-questioning people. Transition is a big step; reversing it can be embarrassing (“uh, actually, turns out I’m a girl, sorry about that”), difficult (“welp, time to save up money for my boob job”), or impossible (“I’m never going to be able to get pregnant”). A lot of signs that one might be trans– depression, dissociation, a strong desire to wear clothing associated with a particular gender, glee when you pass– can also be caused by a lot of other things. Right now, really the only way to figure out whether transition is a good idea is trying it and seeing if you like it. If we understood why people are trans, it could provide gender-questioning people more guidance in figuring out whether transition is right for them.
For instance, let’s say that God comes down from on high and says “yep, the Blanchard/Bailey theory of transness is absolutely and 100% accurate, this is definitely how transness works.” In that case, a lot of very feminine gay men and straight men who jerk off to sissification porn should consider transitioning, even if they have no particular desire to be women– empirically, people who are quite similar to them seem to have found transitioning to be the correct choice. Conversely, assigned-male-at-birth people who aren’t solely attracted to men and who find that crossdressing porn leaves them cold should probably not transition: it’s very likely that their condition is actually depression, a dissociative disorder, or similar.
On the other hand, if God comes down from on high and says “actually, gender dysphoria is a neurological intersex condition, and you can identify it through looking at the differences in these six brain regions”, suddenly it becomes very important to get a brain scan before you consider transitioning.
If God says “gender dysphoria is a lifelong condition and if you didn’t have gender dysphoria before puberty you don’t have it now”, it is ill-advised for me to transition. If God says “gender dysphoria in children is linked to but distinct from gender dysphoria in adults, and gender dysphoric children often grow up to be adults without gender dysphoria”, it is ill-advised to put your gender-dysphoric eleven-year-old on HRT.
To be clear, I support the right of any person who wishes to transition to do so (although perhaps not to have their transition covered by insurance). If we knew that transness was a neurological intersex condition, I would support the right of people without that condition to transition; if we knew that the Blanchard/Bailey theory was correct, I would support the right of masculine people without a sexual fetish for being a woman to transition. But that doesn’t mean their decision would be a good one, and people– naturally– want to make good decisions about such an important issue. So the etiology of transness does matter.
Thing of Things 
Would you say that given the evidence currently available that a person’s own self-evaluation of what will make them happy is still the best guide?
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A comment by Aapje has been deleted for being entirely unrelated to the post, likely to cause discourse that is personally annoying to me, and signal-boosting a Slate Star Codex blog post despite the extremely high overlap between our respective readerships.
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My apologies.
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THIS! I’ve been preaching this to anyone who will listen basically since I learned about Blanchard and AGP, and how so many people are willing to act in bad faith to obscure or suppress any discussion of his and others’ work to preserve their own identity. Maybe you fucked up bro! Maybe you’re going to realize you fucked up and be upset that no one held you to a higher standard than your own feelings!
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I don’t understand what you mean by holding trans people to a higher standard?
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I mean just that we should (and I imagine in most clinical cases actually DO) require more than just self-identification, to better filter people with “depression, a dissociative disorder, or similar” as you say, and event to encourage the transition of people who have no strong sense of transgender identity but are otherwise etiologically transgender (such as the gay and sissifetishizing men you mention)
If etiology were relevant, these groups would be harmed by (in opposite ways) by making transition a merely personal choice.
So the higher standard of which I speak is akin to making your kids study so they develop a good work ethic, or owning letting yourself eat icecream after having done some work. Just trusting that someone other than you knows something about you you don’t, (like parents about their future children, you about your icecream eating self, doctors about their potentially trans patients)
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I do not think we currently know what the etiology of transness is, and given that we don’t know I think that an informed consent model is the least harmful model. Doctors actually don’t know the traits of people who might someday regret transitioning. The best solution is to encourage people to make a thoughtful decision, to try things in reversible ways before they try things in irreversible ways and to collect data so that we may have a better understanding in the future.
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endorsed
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I’m not sure if you’re aware, but your postulated state of information is pretty much where intersex is right now. I’d have to dig out my old med school notes, but from what I recall from the lecture (given by a prominent expert in the field), we understand the genetic basis of all forms of intersex (e.g. this gene mutation will cause the developmental pathway to change in this way and produce this result), can test for the particular mutations, and for many (but not all), we also know what gender identity the kid will grow into with very high certainty (IIRC, kids with certain mutations had 100% identification with one or the other).
Obviously, this doesn’t over-ride issues of consent or autonomy, but does put the “informed” in informed consent; there’s a big difference in recommended course of action for an infant with Leydig cell hypoplasia, which has few major comorbities, and Swyer syndrome with Y-containing gonads, in which case the gonads will almost certainly become cancerous within a year of birth.
On the flip side, as someone who is cis-by-default, the idea of making such a huge and, in some cases, irrevocable decision based only on feelings (however strong they might be) would terrify the shit out of me, because I know my own feelings are unreliable in many matters. Actually having a brain-scan or genetic test would ameliorate that a lot.
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afaik they don’t know much aside from correlations about CAH and gender identity, or is that not true?
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S&I – AFAIK, yes. From what I recall from the lecture, certain disruptions to the pathways produced very dependable results both in terms of morphology and gender identity, while others were more variable, and it all depended on which gene was at fault.
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What cerastes said about feelings is a good point. It makes sense. Sometimes, well, alot of times, I have feeling but find out they’re incorrect. Hate to transition and find out that’s the case here. I just find it easier that if on one day you feel like presenting as the opposite gender, it would be easier, assuming culture accepts it. Otherwise it would also cause more issues than its worth. I rely do wish we’d get to that place though. Although to be fair, we’ve come a very far road to acceptance on this subject in a very short time.
Ozy makes a very good point about what you do with your personal body is nobody else’s business. See it, like it, don’t like it, but keep your opinions to yourself. Alot of that has come from the abortion argument of my body my choice. But mainly for women only. As a cis man, God forbid I have almost nothing else but short hair, facial hair around my mouth. And wear flannel or weave shirts with jeans.
However. There’s a concept coming that I call individualized masculinity. It means that as an anatomical man, how I think, and behave is irrelevant to being a man. It doesn’t mean I’m gay or straight unless I tell you. Or that I wish to transition. Or that I’m into kinky sexuality activities. You don’t get to decide AND act towards me as if that’s the absolute truth.
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It seems that the best research to do to determine which people should transition is research specifically targeting the question “what characteristics make it more and less likely that someone will be happy with/without transition?” This seems much simpler to investigate and answer than “where does transness come from”, and better targeted to be useful in decision-making, too.
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TCH – I would actually argue the opposite. Happy/unhappy is pretty vague and relies on a huge number of social variables, not all of which can be captured, not all of which will be accurately recalled, etc. On the other side, with the cost of genetic data always dropping, it becomes ever cheaper to sequence the genomes, and once you have that pilot data, you can even-more-cheaply screen for putative alleles of interest. You can convince yourself that you really are happy or that your partner really is supportive without either being true, but no act of self-deception will change your genome.
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But, in the end, what matters the most in medicine is outcomes, not genomes. E.g., knowing exactly which piece of which chromosome is missing in your kid will not, by itself, help you decide whether you need to hire a speech therapist.
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“We will tell you what to do with your life (and enforce is) based on genetic screening” is such a dystopian staple that it would take extraordinary evidence to convince me that it’s a good idea. Part of that must be that people are really way waaaay happier this way than with the right to make their own choices. But that brings us back to the point where we could just optimize for happiness in the first place.
Also, “you can convince yourself that you’re happy when you are not” strikes me as a type error.
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I agree with your first paragraph, but whilst technically I think it’s correct that “you can convince yourself that you’re happy when you are not” is a type error, “you can mislead yourself about the causes of the ways in which you are happy and unhappy” is true, and is perhaps the sort of self-deception that Cerastes is concerned about?
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Nita – Without understanding the mechanisms, you’re just fumbling in the dark, though. Sure, you may hit upon things that work, but only in a crude, imprecise manner, and those imprecisions have real human costs in medicine.
To use your own example, imagine if we knew “this gene mutation causes this cluster of neurons to develop abnormally leading to this very specific form of speech pathology which responds well to this treatment, while other treatment forms aren’t reaching the root of the issue and will leave the patient with minimal progress and great frustration.”
Without knowing the mechanism, any study of the effect of speech therapies will naively just throw everyone into one big pot, or group them by broad phenotypes (some of which may be produced by different mechanisms), resulting in a statistical mess that yields incorrect or worthless data.
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Maxim, you’d have a point if your post weren’t a totally baseless strawman. I never said “We should sequence everyone and DEMAND they do what WE SAY!!”, nor anything even close. I said that, if we know the underlying mechanisms and consequences, we can provide patients with “personalized medicine” (buzzword alert) by providing them information on what the likely treatment outcomes are.
I’ll use myself as an example. About 5 years ago, I suffered a spontaneous pulmonary embolism (a blood clot in my lungs). After some heparin to dissolve the clot, I was placed on anti-clotting drugs (coumadin, which is literally rat poison) to prevent future clots. If you haven’t been on it, it SUUUUUUUCKS. I felt like crap, bruised super easily, and if I got in a car accident I would have been fucked.
In the absence of knowledge of the mechanism, medicine would have just been able to say “well, your blood seems to clot spontaneously, so deal with the side effects for the next 50 years or die soon.” But thanks to genetics and molecular biology, we know the biochemistry of clotting (thrombosis), what genes are involved, which mutations present as increased or decreased clotting, and long-term consequences of those genes. I was able to get a simple genetic screen that showed I was heterozygous for Factor V Leiden, which has a 1/800 lifetime risk of spontaneous thrombosis (always on the venous side, no strokes), and no elevation in risk for a second clot. Consequently, I was able to make an informed decision about my health and get off the fucking rat poison pills.
Is there something like Godwin’s Law that states “Any time genetic testing or health is discussed, someone will eventually rant about dystopias”?
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@Cerastes
Yes, that would be nice. But sequencing genomes is not enough to achieve that level of understanding. Worse yet, human physiology is sufficiently complicated to keep nice and clear solutions to most issues out of our reach for a very long time.
And the folks currently going, “there are two species of trans women, they are like dogs and cats, and we’re going to call them ‘transkids’ and ‘autogynophiliacs’ :)” aren’t really doing the kind of work that might yield useful results, IMO — the one thing they seem to be really good at is alienating the people they’re theorizing about.
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Nita: Speaking as a physiologist, I’m actually fairly optimistic about it in this particular system. Sometimes physiology can have a lot of complexities and redundancies that make things difficult, but other times it can be relatively rigid and unchanging, where A depends upon B, and breaking A will always have the same consequence. To use my area (muscle physiology) as an example, if you break a myosin gene, big deal, there’s literally 15 others, at least a few of which are nearly identical. But break titin, even just one of the paired copies, and the entire muscular system goes to shit.
If this were my project, I’d start with a Genome Wide Associate Survey on a recruited group of transwomen who fit one particular “stereotype” as narrowly as possible, and focus on any GWAS hits that are known to be involved in brain development (as opposed to, say, gut nutrient transport proteins, which are more likely to be false positives). If any of those had particularly consistent alleles, you could do a broader survey of the trans population to assess prevalence, while using animal models to track expression patterns during development and engineer some animals with knockouts and alternative alleles.
It’s not easy; we’d be talking probably 20-50 million in grants over a few decades. But not impossible or even necessarily that tough compared to other physiological problems.
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While obviously questions about the true nature of being trans are highly *relevant* to how good an outcome transitioning will have it isn’t the same thing.
Ultimately, what matters to someone facing that choice isn’t whether on some theory or other their body matches (obviously not what a real theory would say but serves the purpose) their mental gender identity. What matters is whether it makes their life better or not.
For instance, we might find out that people like person X have brains witch match a body of the opposite sex. But that doesn’t really help X. It might be that people like X find themselves regretting transitioning because of all the money, time and expense they put into the process with only a minor benefit. Or maybe it turns out that people regret transitioning because it encouraged them to falsely attribute many other psychological issues to their gender dysphoria and fail to deal with them.
The converse could happen as well. Maybe the true theory of gender tells X which match a body of X’s current sex. But if X is desperately unhappy, no matter what the cause, and it turns out that people with X’s psychological issues feel great about themselves and life after transitioning then X should tell nature to go shove it and transition.
Obviously, a scientific theory of gender and gender dysphoria would be hugely helpful in giving the best advice possible. If it turns out that there are 17 different gender related brain types than knowing which type someone is would probably substantially affect the advice one should give them. However, it seems a bad idea to focus merely on coming up with such a theory for several reasons:
1) People will too easily migrate to the false assumption that they should change (or not change) their bodies to match whatever the theory says they should be neglecting the very real effects that issues besides gender identity have on the expected benefits of such a change.
2) The issue of gender and gender identity is simply to emotional and polarized to plausibly hope for consensus on such a theory to emerge anytime in the near future. Regardless of what the theory is it will upset some people’s deeply held beliefs about themselves and, absent the kind of truly incontrovertable evidence found only in the hard sciences, serious doubts will linger for a long time.
In contrast, simply reporting on outcomes or (dare to hope) offering a randomized trial (say offering to pay for transitioning for people who can’t otherwise afford it) has the potential to yield immediate useful information with less spin and confusion.
3) It risks alienating people who are skeptical of the various theories offered so far about gender and gender identity as our skepticism will be interpreted as animosity (even if we actually support people transitioning) if you too closely link the two issues.
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I’m curious about your “covered by insurance” bit, perhaps we subscribe to a different view of what medical care is for.
Under mine while it does intersect strongly with empirical questions like expected outcomes and QALY’s there seems to special reason to exclude transitioning from what would come under the umbrella of healthcare if it makes the QALY cut.
If the evidence shows it effectively treats various problems it seems no less valid a medical intervention than putting someone on antidepressants or into therapy.
That is unless I misinterpreted your “perhaps” and you meant it in terms of something like the idea that insurance should only cover it as a medical intervention if the persons doctors agree that it will likely help the person.
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Correction: “there seems to **be no** special reason”
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IMHO, the biggest question is whether a theory or model lets you make useful predictions about the future. I think that’s your point too, Ozy, but it might be more precise to say we don’t care so much whether B/B is “true” in a Platonic sense, but whether it lets us identify people who will be helped or harmed by transition, and with what accuracy.
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Yes, it matters what is true but do you really think the effect of prioritizing what is true will be to cause people to believe true things. Sure, scientists should totally be funded to look into this but people like to lie to themselves.
Throughout human history people have chosen to believe whatever theory about their nature makes them feel the best. The greeks were obviously the most perfect people because it was climate that determined one’s nature. Poor white people have convinced themselves for a long time of their worth by telling themselves that race was a vital factor in determining one’s ability and virtue.
Also do we really want to correct people on this matter if they are wrong about it but feeling good about themselves as a result?
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