Transgender

Part I: Where We Agree

Over the past couple of decades, the topic of transgender and gender variant identity has reached the forefront in this country and beyond. It is a deeply personal topic and at times, a deeply divisive one.  It is one where individuals and entities often find themselves clashing over moral, legislative, and ideological disputes.  In taking on this series, my purpose is to illuminate many aspects of this issue; simple in theory, yet undoubtedly complex in execution.  First, I will work to explain where individuals and entities largely agree and where they disagree.  Next, I will work to provide a broader historical, sociological, and psychological perspective in ultimately weaving in my dynamic opinions on various matters.  In doing so, I welcome feedback of any kind, but ask for your patience and understanding in taking on this difficult, sensitive topic.  As a father of seven young children, it is particularly important for me to understand what allows for the greatest health and well-being no matter what course of life people take, including my children.

I begin by divulging the sources I used to develop this series.  In addition to my own experience as a pediatric psychologist, I have spent a substantial amount of time pulling together a myriad of sources from the most divergent perspectives I could find.  In the subsequent pages, I will use abbreviations noted below where appropriate, especially when quotes are used.  First and foremost, I am utilizing an increasingly large body of research studies focused in this area.  Beyond this, I sought out position statements and practice guidelines from a number of organizations, including the following:  American Psychological Association (APA), American Psychiatric Association (I will use the abbreviation APCA to distinguish from the APA), American Medical Association (AMA), Catholic Medical Association (CMA), American Academy of Pediatrics (AAP), World Professional Association for Transgender Health (WPATH) and the American College of Pediatricians (ACP).  In addition, I utilized multiple books, including one recommended by the APA entitled, “Affirmative Counseling and Psychological Practice with Transgender and Gender Nonconforming Clients” (CPP).  In addition, National Geographic (NG) dedicated its entire January 2017 edition to this topic in a special issue entitled “Gender Revolution.”

Before beginning this discussion, I also must define necessary terms. This will not be an exhaustive list, but necessary in addressing this topic.  Many sources and opinions are available, but I have elected to pull from the definitions provided in NG as I feel that they are the most consistent and updated.  Terms are as follows. Cisgender describes a “person whose gender identity matches the biological sex they were assigned at birth.” Gender binary denotes the idea that gender is “strictly an either-or-option of male or female,” not a “spectrum of gender identities and expressions.” Nonbinary rejects the absolute notion of either-or, and reflects the idea that gender can be a “spectrum of gender identities and expressions.” Gender expression is a “person’s outward gender presentation” including “personal style, clothing, hairstyle, makeup, jewelry, etc.” By definition, it can coincide or not coincide with gender identity, “a person’s deep-seated, internal sense of…the gender with which they identify themselves.” Sexual orientation is “a person’s feelings of attraction toward other people” regardless of gender identity or expression. Natal sex is a term used to denote an individual’s sex “assigned” at birth as determined by anatomical and/or genetic features.  Ultimately, transgender (sometimes just trans) is the term used to “describe a person whose gender identity does not match the biological sex they were assigned to at birth.”  Transgender is not always synonymous with “transsexual”, which is considered outdated by some and also denotes that an individual has undergone medical changes in identifying with the gender opposite their natal sex.  A good number of transgender individuals utilize cosmetic changes in identifying and/or expressing themselves as the opposite gender without utilizing medical means. Cross gender is sometimes used to denote transgender feelings or expressions.

These terms being defined, I want to begin this series by outlining the general areas of agreement that cut across a wide range of opinions, and include references to specific organizations when statistics or statements are used from their policy statements or practice guidelines. I list these in no particular order.

Sex as defined by genetic markers and anatomical features is binary by nature; all individuals are born clearly male or female with the exception of those affected by disorders of sexual development (DSD’s) or chromosomal abnormalities discussed in the second point. Upon conception, each human being receives two sex chromosomes, which make up the 23rd chromosome pair in the human body (the first 22 are termed autosomal chromosomes).  Males have an XY combination.  Females have an XX combination.  All somatic cells in the human body have identical copies of these chromosomes.  Fetuses by eight weeks of age in utero have been imprinted by sex hormones (boys mainly with testosterone; girls with estrogen).  Infants are born with various anatomical features that match these genetic and hormonal markers.

Disorders of sexual development(DSDs), such as congenital adrenal hyperplasia, androgen insensitivity syndrome, and mixed gonadal dysgenesis, are among the most common DSDs, but are “exceedingly”(APCA) or “very” rare (CMA) in the general population. Prevalence data is limited, but current estimates of individuals with DSDs are 1 in 5,500.  Individuals with DSDs are considered to have an innate biological syndrome and are not necessarily synonymous with transgender individuals, but these conditions can be diagnosed with Gender Dysphoria under the most updated criteria used for psychological conditions (Diagnostic and Statistical Manual of Mental Disorders – 5th Edition).  These individuals may or may not demonstrate transgender identification or expression.

“Many” (AAP) to most pre-pubertal youth with cross gender or transgender feelings do not “persist” in identifying as transgender through puberty, thus as are considered as “desisting” and therefore, will become identified as cisgender. Ultimately, many to most youth identify with a gender that aligns with their natal sex by the end of adolescence.  Estimates are generally that 80-95% (ACP/APCA) will eventually align with their biological sex although some estimates (CPP/APA) suggest a range as wide as 50-88%.

It is very difficult, if not impossible, to identify which children with cross gender feelings will persist or desist through adolescence (APCA) into adulthood. However, adolescents who exhibit or identify with cross gender feelings are more likely to persist into adulthood than pre-pubertal youth who demonstrate cross gender feelings or identity.  Some research (APA) has found that “intensity” of early cross gender feelings in childhood is a predictor of persistence, but the general consensus is that persistence into adulthood is challenging to predict in pre-pubertal youth.  Youth who persist with transgender feelings into adolescence are more likely to sustain this presentation; however, adolescents who present with transgender feelings for the first time often exhibit high levels of psychopathology (APCA).

Transgender youth and adults are at increased risk for also having sexual diseases, substance abuse, anxiety, depression, suicide, non-suicidal self-injury, autism spectrum disorders, and other medical conditions when compared to the general population. Studies have found that over 50% of transgender individuals are depressed (ACP); sexual minority youth are twice as likely to consider suicide (AAP).  While there is substantial agreement on greater rates of adverse conditions and circumstances in this population, disagreement exists on likely causes.  This will be discussed in part II.

Transgender individuals experience higher rates of violence, abuse, family dysfunction, victimization, bullying, and discrimination than the general public. 84% of adolescents who were open about their transgender identity and/or homosexual/bisexual orientation reported verbal harassment and 30% indicated that they were physically injured.  Over 50% of transgender youth reported cyberbullying in the past month (AAP).

Sexual minority youth are more likely to engage in sexual intercourse, and at a younger age, and to have multiple partners, than heterosexual youth who identify as cisgender. In general, findings indicate that sexual minority youth (i.e., those that do not identify as heterosexual exclusively) are more sexually active and at a younger age.  Multiple theories abound about why this is the case, but there is general agreement about greater promiscuity in this population.

Cross-sex hormones, used as part of a medical treatment to reassign sex for transgender individuals, do carry the risk of serious potential side effects, including infertility. Potential negative effects include the following:  cardiovascular disease, weight gain, elevated blood pressure, cholesterol issues, liver damage, risk of sleep apnea, and gallbladder disease among other issues (ACP) in addition to deep venous thrombosis, prolactinomas, increased risk of breast cancer, and decreased libido (AAP).

No randomized control trials/studies (RCTs), considered to be the gold standard in scientific research, exist to examine any aspect of gender identity or gender dysphoria (i.e., significant distress or discomfort with cross gender feelings) – APCA (“expert opinions vary widely”). Current scientific recommendations for treatment and assessment guidelines are based on a synthesis of less rigorous studies (including case studies) and “expert” opinion or consensus.  RCTs with this population are considered by some (e.g., APCA) to be difficult to conduct by many given ethical and logistical (e.g., limited participants available) obstacles.

Transgender identity is considered to be “rare” (APCA), potentially very rare, although prevalence estimates are difficult to verify given multiple factors. Estimates are that less than 1% among children (ACP) and as little as 1 in 11,900 to 1 in 45,000 for MTF youth (male to female youth) and 1 in 30,400 to 1 in 200,00 for FTM (female to male) youth (AAP – WPATH 7th Edition).  “Gender identity and gender expression usually conform to anatomic sex for both homosexual and heterosexual teenagers,” (AAP – Policy Statement, 199). Estimates of boys and girls “wishing to be the opposite sex” ranged from 0.9% to 1.7% depending on sex and age (WPATH – Epidemiology of GID); estimates of transgender, nonbinary adults range from 0.17% to 1.3% (APA).

Gender identity feelings in childhood are associated with increased rates of a homosexual or bisexual identification in adulthood. Homosexual orientation is elevated in adulthood regardless if transgender identification is addressed in treatment (APCA/APA).  When compared with non-gender questioning youth, these individuals are more likely to exhibit same-sex attraction as adults.

Part II: Where Disagreement Remains

I begin Part II of this transgender series in similar fashion as I did Part I, by looking at the various opinions and research that exist on pertinent issues. However, in this article, I will take a closer look at topics that spur the most controversy and division.  Again, I ask for your patience and understanding in taking on this particular task as many perspectives exist; also, I ask that you read Part I before reading the information below.  As in Part I, I will start again by divulging primary sources and defining terms.

In addition to my own experience as a pediatric psychologist (which includes limited experience with youth with transgender issues), I have spent substantial time pulling together a myriad of sources from the most divergent perspectives I could find. In the subsequent pages, I will use abbreviations noted below where appropriate, especially when quotes are used.  First and foremost, I am utilizing an increasingly large body of research studies focused in this area.  Beyond this, I sought out position statements and practice guidelines from a number of organizations, including the following:  American Psychological Association (APA), American Psychiatric Association (I will use the abbreviation APCA to distinguish from the APA), American Medical Association (AMA), Catholic Medical Association (CMA), American Academy of Pediatrics (AAP), World Professional Association for Transgender Health (WPATH) and the American College of Pediatricians (ACP).  In addition, I utilized multiple books, including one recommended by the APA entitled, “Affirmative Counseling and Psychological Practice with Transgender and Gender Nonconforming Clients” (CPP)  and “Transgender Warriors:  Making History from Joan of Arc to Dennis Rodman.” (TW)  In addition, National Geographic (NG) dedicated its entire January 2017 to this topic as a special issue entitled “Gender Revolution.”

Before beginning this discussion, I also must define necessary terms. This will not be an exhaustive list, but necessary in addressing this topic.  Many sources and opinions are available, but I have elected to pull from the definitions provided in NG as I feel that they are the most consistent and updated.  Terms are as follows. Cisgender describes a “person whose gender identity matches the biological sex they were assigned at birth.” Gender binary denotes the idea that gender is “strictly an either-or-option of male or female,” not a “spectrum of gender identities and expressions.” Nonbinary rejects the absolute notion of either-or, and reflects the idea that gender can be a “spectrum of gender identities and expressions.” Gender expression is a “person’s outward gender presentation” including “personal style, clothing, hairstyle, makeup, jewelry, etc.” By definition, it can coincide or not coincide with gender identity, “a person’s deep-seated, internal sense of…the gender with which they identify themselves.” Sexual orientation is “a person’s feelings of attraction toward other people” regardless of gender identity or expression. Natal sex is a term used to denote an individual’s sex “assigned” at birth as determined by anatomical and/or genetic features.  Ultimately, transgender (sometimes just trans) is the term used to “describe a person whose gender identity does not match the biological sex they were assigned to at birth.”  Transgender is not always synonymous with “transsexual”, which is considered outdated by some and also denotes that an individual has undergone medical changes in identifying with the gender opposite their natal sex.  A good number of transgender individuals utilize cosmetic changes in identifying and/or expressing themselves as the opposite gender without utilizing medical means. Cross gender is sometimes used to denote transgender feelings or expressions.

The following is a synopsis of major areas of contention and disagreement:

Gender identity issues, or transgender (or nonbinary) identification and/or expression, is unhealthy, and/or pathological versus transgender, or nonbinary identification, is a normal expression of the human experience, and is “not inherently pathological” (APA).  Two primary opinions exist.  One perspective is that transgender identification, or identification with a range of gender expressions, is a healthy expression of the human experience.  Those that believe this generally reject the notion that gender is both binary and binding according to the natal sex.  The other opinion is that those who exhibit gender identification (of any kind) that does not line up with their natal sex are experiencing symptoms of an unhealthy condition, which may stem from unhealthy circumstances that are both intrinsic in nature and/or from the environment (e.g., family discord, parent-child relational problems).

Transgender adults, once reassigned, are as healthy as the rest of the population versus even after reassignment, transgender adults are at greater risk for a number of physical and psychological conditions.  The primary issue here relates to topic #1, which deals with the question of health regarding transgender identification.  Certain evidence and expertise suggests that once individuals are able to live in the way that is consistent with their gender identification, they exhibit a profile of health that is similar to the overall population.  Other research suggests these individuals remain at greater risk for a variety of psychological conditions that are directly associated with their cross gender expression and/or factors that relate (ACP/APCA).  Research cited in support of this argument includes a 30-year follow-up of individuals who underwent sex reassignment in Sweden, which is reportedly one of the “most affirming” countries for those with transgender identification.  Findings indicated that suicide risk of these individuals was almost 20 times greater among transgender adults than those in the general population.  However, others (APCA/APA) contend that those who go through opposite gender transition show reduced psychological distress, and low rates of regret.  Participants generally labeled outcomes as “favorable”; little or no significant increase in risk behaviors exist for adults who have transitioned to their desired gender (AAP).  However, individuals in these studies are compared to those transgender people who don’t transition, and not the general public.

Elevated psychological/physical issues found in individuals with transgender identity are due to factors of oppression, discrimination, and prejudice, not an intrinsically pathological condition versus increased health problems in this population are due to inherently unhealthy conditions and circumstances that manifest as cross gender feelings. As noted in Part I, most organizations and experts recognize that transgender individuals are generally at a higher risk for a myriad of health issues.  However, the disagreement lies in whether the primary cause is due to societal oppression, discrimination, and violence towards these individuals, or whether transgender is a symptom of circumstance(s) and condition(s) that create an unhealthy state of being.  Those who believe that transgender identity is a manifestation of a pathological and/or unhealthy condition cite various findings that indicate high rates of psychopathology, childhood adverse events, family issues (e.g., fathers spending less time with “feminine boys”, high rates of maternal psychopathology), media effects, peer influence, and other factors as increasing the likelihood of having a trangender, or nonbinary, identity.  An article (Journal of Homosexuality, 2012) was published by the director, Kenneth Zucker, (and colleagues) of a Gender clinic started in the mid-1970’s in Toronto.  They reviewed findings from almost 600 youth referred.  Findings noted many psychosocial factors that were associated with (and often treated) transgender identification in youth.  In contrast, other organizations emphasize that being transgender “is not, in itself, a risk behavior and many sexual minority youth are quite resilient; sexual minority youth should not be considered abnormal.  However, the presence of stigma from homophobia and heterosexism often leads to psychological distress, which may be accompanied by an increase in risk behaviors.” (AAP – Policy Statement, pg. 198)

Gender identification is innate to the individual, whether of cross gender, cisgender, or nonbinary versus gender is influenced by many different factors.  There is a diversity of opinions on this matter.  Some experts indicate that gender identity is innate, and therefore, immutable.  Supporters of this idea cite multiple MRI studies that have found anatomical brain differences in transgender individuals, including adults, that suggest they show some, or greater, resemblance to brains of the opposite sex.  Critics argue that studies are both flawed by small sample size, and by the fact that brains can be significantly altered by experiences of various kinds (ACP).  Others feel that gender expression, especially cisgender expression, is largely influenced and mandated by culture.  Still others contend that although gender expression can be influenced by cultural, familial, and other environmental factors, gender and sex are inextricably linked together.  Those who believe that transgender identification (e.g., ACP) is largely a result of post-natal experiences (e.g., unhealthy conditions/influences, peer influence) often cite the largest study of identical twin transsexual adults (which contain a 100% of the same genetic material).  Eighty percent of the twins were “discordant” in regards to gender identification; therefore, they both did not identify as transgender.

Youth with transgender feelings should be given opportunities prior to adulthood to pursue their identification through social and medical means versus supporting and providing youth with these options not only creates greater risk for them, but also increases the likelihood that they will persist with cross gender identification for the long-term.  The essence of this debate centers on whether youth, as minors, should 1) have a right to advocate for means of transition to the opposite gender prior to 18, and 2) whether it is healthy and/or ethical for parents, school personnel, medical professionals, and/or other caregivers to support this transition.

Puberty-blocking drugs are fully reversible and safe versus puberty blocking drugs increase the risk for harm, and the likelihood of youth persisting as transgender into adulthood.  Related to the previous issue, the controversy here involves whether puberty-blocking drugs are safe and/or ethical, and whether or not they truly are reversible and/or not influential of a person’s ultimate gender identification.  Some experts contend that these hormones can affect brain development, arrest bone growth, and decrease bone density among other issues.  A combination of puberty suppression with cross sex hormones is believed by some to result in infertility (ACP).  Similar camps also cite evidence that puberty suppression drugs increase the likelihood of cross gender identification long-term;  in regard to this concern, one study (CMA position statement – Journal of Sexual Medicine, 2011) found that of 70 children diagnosed with gender dysphoria who started puberty suppressions, all eventually moved forward with cross gender hormones (first step of gender reassignment);  this contrasts with the field studies (previously noted) which find that many to most youth will naturally not persist with cross gender feelings through adolescence if not facilitated in this identification (e.g., by hormones, other cross gender interventions). Others (APCA) contend that a period of up to a few years is safe for these puberty suppression drugs, and that although side effects can exist, this is not commonly seen.

Part III: Moving Beyond Gender

I begin Part III with a historical look through the ages. Eight thousand years ago, the author of Genesis wrote what is one of the oldest surviving statements on sex and gender.  “So the Lord God cast a deep sleep on the man, and while he was asleep, he took out one of his ribs and closed up its place with flesh.  The Lord God then built up into a woman the rib that he had taken from the man.  When he brought her to the man, the man said:  This one, at last, is bone of my bones and flesh of my flesh; this one shall be called ‘woman,’ for out of ‘her man’ this one has been taken.”

Around the same time period, the first edict against cross-dressing appeared in the book of Deuteronomy (22:5): “A woman shall not wear an article proper to a man, nor shall a man put on a woman’s dress….”  As indicated by the need for a warning, cross dressing and posing as the opposite sex is not a new phenomenon.  As detailed in the book, “Transgender Warriors” by Leslie Feinberg, tales exist across all time periods of men and women crossing over the sex barrier.  Thousands of years prior to the current era, stories of transsexual male-to-female priestesses (which often involved castration) worshipping the goddess of the Great Mother are found in many areas of the world.  Feinberg makes the case that early societies were often female driven (in regards to transmission of title and property), and that patriarchal shifts came about as means of wealth accumulation and preservation embedded within religious practices.  Interestingly, the previously used term “hermaphrodite” (now considered derogatory by many) came from the legend of Cupid (known as Eros by the Greeks), child of Hermes and Aphrodite.

Over the past two millennia, stories of “transgender” individuals continued to appear in unexpected places. A number of canonized Catholic saints were found to be women posing as men only after their death, including St. Pelagia, called the “beardless monk.”  St. Joan of Arc remains the most famous cross dressing saint although the impetus of her male attire varies depending who is telling the story.  Reportedly 400 Civil War soldiers in the U.S. were found to be women at a time when combat was not an option for females.  In many Native American tribes, certain individuals have long been revered as “Two Spirits”, people who were considered neither man nor woman, yet held a distinctly unique place in the tribe.  Various rebellions, whether in Greenwich village by black and Latina drag queens or “Rebecca and her daughters” (men dressed as women) in Wales dot the historical landscape along with various individuals at many places and times posing as the opposite sex.

Despite a history of varied expressions, though, as noted by Michelle Cretella (ACP) and other authors, a shift began to occur in the use of gender versus sex in the 1950’s and 1960’s. Prior to this time, gender was used for grammar and not for people.  It was used for nouns and their modifiers as being masculine or feminine in Latin-based languages.  But from this point until the present, an increasing number of professionals and lay public began to use gender as a means of describing how people feel in regard to sexual identity and expression.  This linguistic change signified the idea that gender was an internally and societally-driven concept even though the genes and biology of sex had not changed.  In other words, it supported the notion that an individual (although likely influenced by many factors) determines their gender, not acquiesces to what was granted at conception.

Today, as more fully articulated in the book The Global Sexual Revolution by Gabriele Kuby, the idea of “gender mainstreaming” has spread throughout many worldwide organizations, including the United Nations (UN).  As noted on the UN website, “Gender Mainstreaming is a globally accepted strategy for promoting gender equality. Mainstreaming is not an end in itself but a strategy, an approach, a means to achieve the goal of gender equality. Mainstreaming involves ensuring that gender perspectives and attention to the goal of gender equality are central to all activities – policy development, research, advocacy/ dialogue, legislation, resource allocation, and planning, implementation and monitoring of programmes and projects.” In describing gender, the UN notes the following:

“These attributes, opportunities and relationships are socially constructed and are learned through socialization processes. They are context/time-specific and changeable. Gender determines what is expected, allowed and valued in a woman or a man in a given context.”

No mention of sex (as defined by genetics or biology) is made in the UN description of gender.

A few months ago, I sat down with a friend and colleague who identifies as a cognitive feminist therapist. In addition to identifying faulty and unhealthy cognitive assumptions, she noted that the feminist connotation of her therapeutic orientation originally stemmed from the feminist movement from decades ago; currently, though, this therapeutic modality is intended to address all types of oppression and inequities that may result in psychological distress or impairment. In thinking about this further, I was struck by the fact that what started as oppression related to gender (in the sense of feminism) had come to be a focus of oppression of all kinds—yet the gendered term remained.

In her book, Feinberg speaks to a few themes that repeatedly resound in the story of “transgenderism” from a historical and ideological perspective. In the opening pages (x), she states “I am transgender and I have shaped myself surgically and hormonally twice in my life, and I reserve the right to do it again.” Relatedly, as stated in the Affirmative Care (AC) book noted in Part I, “AC trusts that the individual knows themselves” and in making this statement, does not distinguish between youth and adults.  As Feinberg says at the end of her book (pg. 105), “It all comes down to this.  Each person has the right to control their own body.  If the individual doesn’t have that right, then who gets to judge?  Should we hand that power over to the Church or the state?  Should we make these rights subject to a poll?”  Ultimately, this speaks of the theme of absolute autonomy over self, and the idea that each person has the right to do what they will to their body based on the desires and feelings they have.  It is probably one reason that tattoo parlors are one of the fastest growing private businesses of today.  It is one major reason that some medical professionals support minors in their access to reproductive medicine without parental consent.

Yet to understand the surge of autonomy and provide any analysis of the “gender revolution”, we must first empathize with the experience of prejudice, discrimination, and oppression that so many have felt. Up until 2003, sodomy laws existed in which consenting adults could be arrested in their own homes.  Cross dressing men and women were repeatedly arrested in the mid 50’s and early 60’s through raids into night clubs and bars.  It has been less than a hundred years since women in this country gained the right to vote, or even could get higher education, open a banking account, and undertake many professions.  However as noted, the rise of transgender advocacy ties into not just sex or gender, but oppression of all kinds.  Oppression of Native Americans to conform to the colonist’s ways.  Oppression of black men and women through slavery and segregation.  Oppression that remains today.

Having said this, Feinberg and others make the point that it would be a mistake to think that transgenderism would simply “go away” if oppression did not exist, as they regularly cite the numbers of men throughout history who became the “oppressed” in living a life as a female after being born a male. No doubt certain individuals feel a sense of discord between their sex and gender even as the darkness of oppression or the desire for autonomy is still very early in awareness.  Yet, at the same time, as transgender identity reaches the mainstream, we also must not ignore the power of social movements of any kind.

Critics of the binary system of gender are quick to point out that the Western ideals indoctrinates male and female identity from the moment that the girl wears pink and the boy wears blue in the maternity ward. They note that children from the youngest age are assimilated into a system that dichotomizes and limits gender expression in countless ways, and therefore, restricts an individual’s ability to be who they desire to be.  Ironically, this restriction is more evident with males today, as masculine women are much more widely accepted than feminine men.  Consider that a man wearing a dress in public is an immediate eye turner while a female wearing pants is par for the course.  Adults and peer groups are generally less tolerant of cross sex behaviors in boys.  Boys are referred to gender clinics earlier.  In one study (Zucker & Lawrence, 2009) of specific questionnaire items that helped determine a referral to more intensive services, “behaves like the opposite sex” was rated as being in the top 35%  for boys (i.e., high likelihood of referral) whereas the same item for girls was near the bottom 10%.  No doubt culture and society play a role in gender induction.

Yet if we are to accept that gender expression of a dichotomous sort (e.g., male or female) is partly a societal construct, then it seems logical to assume that the inverse must also be true.  Again, there have likely always been individuals who found discord between their biological sex and “assigned gender.”  Yet just as culture might influence a binary mode of gender identity/expression (not sex), so we must not be naïve to assume that influences of many kinds (even beyond anything inherently pathological and/or traumatic), whether it be media, peers, familial circumstances, or the like could have the ability to influence a transgender identification or even sexual orientation.  As an example, over the past few years, I have had an increasing number of children and teens who have told me they are gay, lesbian, or bisexual.  When an ensuing discussion followed, it has been interesting (and concerning) to note that the manner in which these terms have been used has considerable variability in connotation, including a meaning that would be best described as a “close friend” when it comes to a feeling of intimacy with another peer.  Yet as the vernacular and societal attitudes have evolved, so has the way that our youth increasingly define who they are to others and themselves in regards to sexuality.

Which brings us back to this whole issue of transgender or nonbinary identity. There seems little doubt that this experience or expression is not a new phenomenon.  But what remains at serious doubt are just what mechanisms are at play, and how this intersects with one tremendously important question: Just what is healthy? It may anger some that I even pose this question as if I or another person have the right to judge.  Yet as health costs and premiums skyrocket across this country largely due to increasingly “unhealthy” lifestyles, and we as providers are asked to address the health crises, it is clear that no one is disconnected from another.  If insurance companies increasingly pay for cross gender interventions, if younger and younger individuals seek transgender options even without a single “gold standard” study being available to direct us to best practices, this issue, however unpopular, remains part of the public domain.

Feinberg is right. We, as autonomous adults, all reserve the “right” to do what we want or feel to our bodies as long as this doesn’t jeopardize the rights of another.  Yet every medical professional has the similar right to autonomy when it comes to doing what they feel is right and just.  It is interesting to note that when Feinberg indicated that she had the “right” to shape herself surgically and hormonally, this statement wasn’t technically true; what she meant was that she had the right to demand that a medical professional do this for her, as she herself couldn’t do it alone.  But in an area where no gold standard studies exist and much disagreement remains, the topic of autonomy is just as salient for providers and payers as it is for transgender individuals.  A government founded on ideals designed to pursue the “well-being” of individuals shouldn’t necessarily be swayed by the same drive for autonomy if it doesn’t support the well-being of the population as a whole.  Ultimately, the question of health is the paramount issue in this discussion.  It deserves our full attention before any attempt at determining best practice should be made.  Discrimination and prejudice are evil, but their presence does not mean that a full support of ideals and trends for which they are levied against is automatically right.  It would be wrong for me to treat someone of transgender identity as less of a human being than myself.  But this doesn’t mean that it is automatically right for me to accept and implement this person’s beliefs in exchange for my own, especially if I as a medical professional am first to “do no harm.”  It is a mistake often born out of good intentions, but it remains a mistake nonetheless.

As a final note on the issue of autonomy, consider the term I first learned in reading the “Affirmative Care” book cited earlier. It is the term adultism, which carries a similar negative connotation as racism, sexism, ageism, and classism.  Adultism is defined as that “which involves having limited power and autonomy over one’s life and decisions [as youth].  Being controlled [my emphasis] by adults in power (i.e., parents, teachers, healthcare providers) may result in increased psychological distress and despair for youth who are struggling to understand and embrace an identity that is not traditional.”

I understand full well that authority can be rendered abusively, arbitrarily, and uncaringly. But if you read the definition of adultism closely, it should make you nervous as a parent and as a society member for what it implies, and what it may seek to threaten. Racism was never a condition of a healthy society.  But parents raising kids is, especially given that a huge body of research supports the need for parents to be quite involved in adolescents’ lives given that their brains are far from being fully developed.  Yet, adultism seems not far from pathologizing and undercutting the very unique relationship that our world has always been founded upon—that of a parent and a child.  Elimination of oppression and respecting reasonable autonomy are noble goals.  Undermining parental authority is a disaster starting to happen.

Part IV: In Pursuit of Health and Well-Being

I am a white, cisgender, heterosexual male. I have lived a life relatively free of discrimination and prejudice (unless you consider the frequent reactions I receive in having many kids).  As a youth, I could not have imagined what it would have been like to be mistrusted, undermined, and harassed for aspects beyond my control.  Even today, after countless learning opportunities and personal experiences with those of a minority status, there is no way I could fully understand what it would be like to be black, gay, or transgender.  But what I do know is that prejudice and discrimination continues to be a destructive and divisive force in this country and this world, and I am not free from guilt in this matter.  Although I pride myself on being egalitarian and empathetic, I harbor unconscious and conscious stereotypes that affect the way I act, and rationalize an internal cowardice that has led me to turn a blind eye in situations where I should have stood up against wrongdoings motivated by differences.  I have much to learn.

Given these circumstances, though, I hope that you will allow me to enter into another type of conversation with regard to the topic of transgender. It is a multi-faceted topic that seems so basic and obvious, yet surprisingly these themes are not uttered in countless books and articles about this issue.  At best, it is a significant oversight; at worst, it speaks of a unilateral agenda.  To begin, I come back to a topic that I began discussing in Part I, which are the scientific findings regarding the increased rates of negative psychological, social, and physical outcomes of those who are transgender.  As mentioned, the disagreement lies with regard to the causes; some feel these negative outcomes are the primary (or sole) result of prejudice and discrimination while others, such as me, feel questions still exist.

It goes without saying (but is rarely said) that the moment a person begins to feel that their gender identity doesn’t align with the body parts they were given, it must be a difficult, confusing time. Beyond any clothes, accessories, or societal gender expectations that a person might feel, the sense that their mind and body aren’t aligning would understandably evoke angst of many kinds.  I say this not only from a logical standpoint, but also in regards to what transgender individuals have said to me personally.  So much about our contentment and happiness has to do with living in harmony with ourselves.  When we “feel” that something is amiss (such as a depressed person feels with his or her moods, sleeping patterns, and/or interest in normally fun activities), a lack of harmony regarding mind, body, and spirit creates “tension” that is both uncomfortable and undesirable.

Consider that a number of defined psychiatric conditions involve a similar disharmony. Those with psychotic conditions, such as schizophrenia, perceive voices and images that do not exist in real form.  People with body dysmorphic disorder (DMD) are “preoccupied with one or more nonexistent or slight defects or flaws in their physical appearance” and “perform repetitive, compulsive behaviors in response to the appearance concerns.” Individuals with anorexia get to dangerously low levels of weight, and possess an “intense” fear of gaining weight due to a “disturbance in the way in which one’s body weight or shape is experienced.” Body integrity identity disorder (BIID) is a rare condition (currently in the proposed category of diagnoses in the Diagnostic and Statistical Manual of Mental Disorders – 5th Edition [DSM-5]) in which seemingly otherwise healthy individuals experience a “dysphoric feeling that one or more limbs of one’s body do not belong to one’s self”; thus, they often desire to have them removed or incur another type of disability (e.g., blindness).  Although not an exhaustive list, each is considered a psychiatric condition, and thereby deemed unhealthy and abnormal for the human condition.

Yet when a similar discontinuity or disharmony involves sex and gender, many “experts” endorse a shift in thinking. Prior to May 2013 when DSM-5 was launched, Gender Identity Disorder (GID) was diagnosed when a person experienced “a strong and persistent cross-gender identification” and “persistent discomfort” (not merely a desire for any perceived cultural advantages of being the other sex) in regard to their biological sex. However, this changed with DSM-5. The new term of Gender Dysphoria is now used to denote that a diagnosis should only be made if an individual feels “distress” about the incongruity between their biological sex and gender identification, not merely identifies as transgender or has persistent transgender urges. Some experts that support this change in terminology explain that distress isn’t necessarily inherent with gender identity issues, but is often culturally or societally induced.

Again, we must pause to consider what is being proposed. This line of reasoning is not only different from so many other psychiatric paradigms, but also suggests that “distress” would not be a common occurrence in those who experience a discontinuity between mind and body.  If depressed individuals engage in cutting or binge eating or isolative behavior, this is considered a significant concern.  If a 5 foot, 6 inch woman with anorexia desires a body weight of 85 pounds, this would be considered pathological and dangerous.  If someone with BIID tried to convince a surgeon to amputate a healthy finger or arm, this would be considered outrageous.  But how is it that when an adolescent asks to consider puberty suppression or cross hormone use, or an adult embraces a full anatomical sex change, we as professionals and a community are told by some “experts” that we should see this as “normal” and “healthy?”

Again, as I realize this is a sensitive subject, I want to stress that all people have the right to feel and experience what is genuine to them, even if it is perceived by the majority as abnormal, unhealthy, or bizarre. And no matter what they experience, we all should seek to be as empathetic, loving, and understanding as possible, and no differences (of opinion or position) ever justify undue prejudice, harassment, and discrimination at any level.  A person with a transgender identity is just as much of a person as you and I; they should be honored in this way, and embraced for all the gifts and talents they have for all of us.  But that doesn’t necessarily mean that what they are experiencing in regard to their sexuality is healthy.

Consider even a broader perspective about what happens when we as human beings find ourselves at odds with the natural rhythms and designs of the human body. Our country is currently in the midst of a great sleep recession as I have written about much before. Many adults and youth are sleeping much less than their bodies demand, either out of desire or a pressured need to stay up late, or difficulties with sleep itself.  Yet regardless of personal or societal factors, our bodies are revolting against this sleep crisis, and right now our country (and millions of people in it) is paying a massive psychological, social, and physical price.  The same thing could be said in regard to our problems with the overconsumption of food, poor nutrition, and limited activity.  Many human beings find themselves desiring (or resigning to) a lifestyle that restricts movement and ignores dietary recommendations despite our body’s clear needs.  Now obesity is the number one cause of death in this country and we again find ourselves in a huge crisis with one basic origin:  we are revolting against the natural design of our bodies.

So I come back to this issue of gender identity, and I again ask the question. Is it “healthy” to persist in a transgender identity, even to the point of sex reassignment?  Couldn’t or shouldn’t transgender feelings arouse some level of discomfort even if society didn’t sanction it?  Interestingly, in many books and articles where I must have read thousands of statements regarding the understandable harm that prejudice and discrimination can bestow on transgender individuals, I literally found no statements raising or suggesting these previous questions.  Not a few.  None.

Meanwhile, in these same and many other texts, I found tons of references to the HIV crisis that exists in lesbian, gay, bisexual, and transgender (LGBT) individuals even after decades of widespread public health initiatives to encourage “safe sex”; yet again, though, there was a glaring omission which regularly seems to occur in discussion of gender or sex-related matters. The Center for Disease Control (CDC) reports that “Gay, bisexual, and other men who have sex with men (MSM) made up an estimated 2% of the population but 55% of people living with HIV in the United States in 2013. If current diagnosis rates continue, 1 in 6 gay and bisexual men will be diagnosed with HIV in their lifetime, including 1 in 2 black/African American gay and bisexual men, 1 in 4 Hispanic/Latino gay and bisexual men, and 1 in 11 white gay and bisexual men.”  Considering the original statistic (2%…but 55%), this indicates that MSM are at approximately a 6,000% greater risk for HIV than the rest of the population.  This is an unimaginable crisis for this community and our world.

To the credit of the CDC, they go onto say the only 100% way to prevent HIV infection is abstinence from anal, oral, and vaginal sex. But it seems that they skirt an obvious, likely reality that I have only heard explained by Miriam Grossman and in a few other articles.  That is, there is strong scientific evidence that anal sex itself is a risky, unhealthy activity due to specific physiological and anatomical features.  In fact, this idea was endorsed in a 2012 article in the Lancet, one of the most prestigious medical journals in the world.  After an extensive analysis of HIV transmission, the authors concluded “the greatest reductions were associated with the scenarios that entailed reducing transmission probabilities [of anal intercourse] to those of vaginal intercourse; in all settings, this quickly reduced incidence [of HIV] by greater than 80%, and in some by as much as 98%.  This emphasizes that the biological factors specific to anal sex have a fundamental effect in driving HIV epidemics of MSM worldwide.”  The article went on to resign that wide scale anal sex will continue.  But no doubt that the findings suggest a clear case of biology attempting to inform practice—no matter what current trends are.

Again, I understand this is a sensitive issue. I recognize that this finding could turn out to be an inconvenient, and difficult reality for some who are unable (or lack the desire) to engage in vaginal intercourse.  But what if it is true, and the act of anal sex is largely responsible for the AIDS epidemic that is ripping through the male LGBTQ community?  Beyond any political or cultural uproar that this might induce about supposed motives and agendas, do we not care enough about each other to move beyond this rhetoric to consider what is healthy or not, with regard to gender and sexuality or otherwise, including for our youth (of any sexual leaning) that depend on us to provide information about healthy practices?  This is not a case of telling someone that they are bad or immoral; this is a case of being honest with people regarding the risks that they might be assuming if they act in a certain way, whether in regards to sexual practices or gender alignment or any other circumstance.

If that wasn’t enough, I have one more final question. What if beyond all of the cultural barriers and past oppressions, beyond all of the confining expectations and even health questions, what if one more potential issue might be responsible for the distress and unhealthiness that LGBT individuals experience?

What if many or most people who experience cross gender feelings still have some desire for a cisgender, heterosexual existence because for thousands of years, the innately desired way to bear and raise children was in a home where a mother and father resided. I know in this day and age, many might regard this as an antiquated, majority, heteronormative philosophy.  But what if beneath the culture, there is a deep biological, genetic underpinning that draws many people to a familial existence where they would conceive their own children, and raise them as mother and father?  Of course, I believe that not everyone is called to this identity, as some are called to different vocations and pursuits greatly needed in this world.  But what if the pressure that many transgender individuals felt to conform to this ideal wasn’t solely of a cultural, societal source, but also of a visceral, biological one?  There is scientific evidence beyond the scope of this article to suggest that what I am saying is not just plausible, but very possible.  But beyond the evidence, I just ask you to consider.

As I said in the beginning, I am a white, cisgender, heterosexual male who has lived a life largely free of prejudice and discrimination. I need to stop taking that for granted.  But I am also a member of the human race, and I don’t care if you are transgender or bisexual or nonbinary or whatever term you might feel is most appropriate.  You deserve compassion and truth-seeking as much as I do, and you deserve to understand why you feel the way you feel.  Without knowing you, I can promise that I want the best for you as I do for my own kids.  Frankly, I care little about the political or legal landscape in this matter.  I care about you, and the world that you and I are cultivating for our kids and their kids to come.

Part V: Reflections on Our Genes and Biology

Any discussion regarding sex or gender issues must first consider just what allowed this discussion to even be possible in the first place. Unlike certain basic organisms, humans, like many other animals, have a genetic system that defines sex in its own way, regardless of what our culture or society does.  The human genome may be the most remarkable entity that exists in this entire universe, not only for its complexity, but also its ability to provide a framework for the person each of us is today.

In starting with the basics, all human beings, with the exception of those who have abnormal genetic conditions, have exactly 23 pairs of chromosomes. The first 22 are called autosomal chromosomes, and are homologous with each other, which basically means they have the same size, structure, and position.  The first autosomal pair is the longest; the 22nd pair is the shortest.  Meanwhile, the 23rd pair is called allosomes, or sex chromosomes.  They differ from autosomes in many ways, one of which is that for males, the pairs differ in size and shape.

Allosomes determine sex in the human species, and all sex characteristics in males and females are initiated by genes on the 23rd chromosome pair.  Males have an XY pair; females have XX.  All human beings inherit an X chromosome from their mother, and it is the father that determines the sex of the child.  If the father contributes an X chromosome, then the child will be a female.  If the father contributes a Y chromosome, then the child will be a male.  Once the child is conceived either male or female, then every single somatic cell in the human body gets a copy of the sex chromosomes.

Interestingly, the X chromosome has about 1,000 genes, roughly 10 times more than the Y chromosome.  Not all genes on the X chromosome are related to sex characteristics.  Most are actually associated with other traits or conditions.  In fact, some conditions such as hemophilia or color blindness, are called X-linked.  On the contrary, the Y chromosome is much smaller in size, and many of its genes have to do with other items besides physical sex characteristics, such as sperm production and health-related factors.  Just one gene on the Y chromosome, the SRY gene, is responsible for male anatomical traits.  When this gene is compromised, it can lead to disorders of sexual development (DSD) in men. Not all vertebrates utilize an XX or XY system as mammals do.  Some birds, reptiles, and even insects use a ZW system that is somewhat opposite of what we see in humans.  Males have two of the same chromosomes (ZZ) and females have differing pairs (ZW).

It is easy to get lost in the complexity of the genome system, but in reflecting on it, there are also remarkably simple aspects of it that seem important to consider. First, whereas all of the characteristics of the human person, such as height, bone structure, temperament, eye color, and functionality, are determined across the chromosomes, one is not.  That one characteristic is the anatomical features that determine sex and reproduction.  No matter how you conceptualize the origin of the human makeup, it is curious to consider that its design clearly put a premium on differentiating these features.  Just like any other trait or feature, anatomical features of sex could have been initiated from various chromosomes.  But instead, X and Y appeared, unlike all other pairs of chromosomes, and made it clear that men and women were created distinct just as their chromosomes that initiated their differences were.  In the thousands of pages I have read on the transgender topic, it surprises me that no one has taken the time to consider the potential message of this genetic reality. Furthermore, it is interesting to note that the father “determines” the sex of child, obviously not by some conscious choice, but certainly by an unconsciously anatomical one.  The sperm pursues, the egg waits.  And yet at the same time, it is the X chromosome, the legacy of our mothers, that carries a huge amount of genes.

All of this is relevant because the discussion of gender often starts with the phrase “sex assigned at birth.” But in reality, sex was defined at conception, and no one in the scientific world disagrees with this idea.  Our genome leaves no equivocation.  Of course, how we ultimately feel and express our gender leads to much other discussion.  But I would suggest that the phrase uttered by Simone de Beauvoir “One is not born, but rather becomes, a woman”, often utilized as a rallying cry for the transgender movement, is both true and not true.  She [in the broad sense of the word], except in cases of DSDs, is born a female and does not become one.  However, she is born as a girl, and becomes a woman, in however she ultimately expresses this.  But her genes don’t lie.

Neither do the physical features that are part of the phenotype of our genes in spite of exceptions that may emerge.  For starters, there are obvious sexual anatomical differences that are apparent at birth and in puberty (e.g., penis vs. vagina, chest vs. breast) that lead to starkly different roles when it comes to conception, gestation, and early child rearing.  From there, men have Adam’s apples (excessive protruding cartilage around the voice box) and larger voice boxes altogether (thus the deeper voices).  Men have a much greater concentration of hair all over their body, and the ability to grow beards.  Women generally have half the strength of men in the upper body, and two-thirds in the lower half while women and men also store their fat differently; men also typically have greater bone mass and a lower percentage of body fat.

Yet these familiar sex differences are only the beginning. The American Physiological Society (APS) notes even further distinctions as part of its recommendations for basic medical curriculum.  In addition to sex hormone differences and starkly different rates of transmission for a number of sex-linked diseases, differences exist in most organ systems.  For example, men have wider airways and larger lungs even when height is accounted for, and have larger left-ventricular mass and chamber size in the heart.  Women have a higher resting heart rate and lower resting blood pressure.  Well-defined structural differences in the brain have been documented that work in concert with sex steroid hormones that lend themselves to distinctly male versus female practices.  As noted in the article “When Is a Sex Difference Not a Sex Difference? (pg. 85), “For neuroendocrinologists, there is no debate on whether there are sex differences in the brain, including humans. The obvious sex differences in reproductive physiology; females ovulate on a periodic and regular basis, get pregnant, deliver, and lactate, and males do not, necessitate that the brain regions regulating these diverse profiles be different.”  Collectively, these are just a few of the many sex differences that exist outside any socialization or psychological factors that may be discussed as driving gender.

Of course, exceptions can exist. But what genetics and biology teaches us is that men and women are not created equal in function and structure although equally deserving of dignity and respect.  Yet in regards to the ideas of gender mainstreaming and non-binary identification, the lesson of biology and genetics is that these ideas come with great risk.  Just as any revolt against our biological makeup carries many potential consequences, so it seems that a clash between sex and gender carries the same inherent peril on an individual and global scale.  The science of gender identity lags far behind the science of sex identity, yet worldwide, many seem ready (or have already begun) to move forward with gender-based ideas of identity without having the scientific framework to do so.

On this note, I close out this series with a few simple reflections of my own:

  • I have no doubt that men and women have had cross gender feelings and identification since the beginning of time, and that a select few were born with disorders of sexual development (DSDs). We as medical community need to find a more scientific, compassionate means of working with all who are afflicted with a DSD from the point it is identified.
  • I have no doubt that various societies have long been guilty of restricting men and women to specific modes of gender expression and gender roles. We need to continue to identify how this affects people, and understand how deeply held values and beliefs can also co-exist while not unfairly “confining” men and women.
  • I have no doubt that society has long abused, disrespected, discarded, discriminated, and disenfranchised those who do not adhere to typical gender roles. We all must continue to address these travesties when they occur, but also why they occur (in understanding the full picture).
  • I have no doubt that both innate and cultural factors influence how people identify as males and females.
  • Yet, I have serious concerns that identifying as transgender or nonbinary is a healthy alternative for which anyone can or could aspire.
  • I have serious concerns that we as a society should be supporting transgender or nonbinary identity as a cultural ideal instead of doing everything possible to promote the healthiest alternative, that is, aligning gender with sex.
  • I have serious concerns that in our noble attempt to empathize and address sexuality issues that are not “mainstream” or “majority”, we may be (intentionally or unintentionally) undermining practices and values that provide a core basis for our society as a whole.
  • I know we can do better for all people in regard to sex and gender issues if we put aside the politics of divisiveness and ideology that hamper sincere efforts to improve understanding and outcomes.

As a psychologist, I am charged with empathetically treating each person I see with the best information and practices that exist. Similarly, as a society, we must adhere to the best practices and knowledge that we have in the midst of a complicated, unclear landscape.  And for as long as humans have existed, even in situations of gender nonconformity and cross gender expression, our genes and our bodies remain the best guides we have.  Until this changes, it is critical that we as a society do not abandon what we know to be true for what feels to be true even as in our offices we discern what is best for each individual.  History has taught us repeatedly that when we do, dire consequences result.  Do we dare ignore this lesson again?

I began this series with an acknowledgement of the sensitivity of the matter at hand, and my goals in addressing this topic. Yet having read the entire series, some of you may find yourself angered about various information, beliefs, or ideas I have put forth.  You might find yourself feeling that I, as a mental health professional, am once again utilizing my position and perceived “authority” in a way that is not helpful, or is even harmful, to individuals and the population as a whole.  Frankly, this reality is one of the reasons that I most dislike being a writer or speaker on difficult matters such as this; no matter what I say or do, I realize that each person will form their own opinions, sometimes negative, about what I say.  But just like you, I must adhere to two universal goals that I believe we should all embrace.  One, to seek out and pass along the best information available.  Two, to be honest, in a respectful manner, regarding the thoughts, feelings, and beliefs I have while always seeking to grow and learn in both areas.  I have worked really hard to do this here, and I ask that you the reader, my neighbor, considering aspiring to the same two principles.  If this happens, and we come together in this way, I am certain that the outcomes for all will be much better than we could have imagined.

A few weeks ago, our 7th child, Samuel Augustine, was born into this world.  Helpless as can be, his arms extending upward and his cries echoing in the early morning hours throughout our home, I could not help but be once again reminded that the only thing that matters is what is truly best for him.  He knows nothing of agendas or politics or religious affiliation, but he is hungry for what feeds and fills him, and desiring of the sounds and touch that comfort and soothe him.  I am forty years older his senior. But it dawns on me that just as I want these things for him, I desire them, too.  I owe it to him and his siblings to go search in what is real and good.  And we really owe this to each other.  He, like all of my children, will ultimately make his own decisions when he gets older.  But in the meantime, it is up to me and his mother to pave a pathway of knowledge and discernment that helps guide him to the healthiest decisions he can make.  I ask you to join us in this way.

Primary Sources

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Websites:

American Psychological Association (APA) – http://www.apa.org/

American Psychiatric Association (APCA)- https://www.psychiatry.org/

American Medical Association (AMA) – https://www.ama-assn.org/

Catholic Medical Association (CMA) – http://www.cathmed.org/

American Academy of Pediatrics (AAP) – https://www.aap.org/

World Professional Association for Transgender Health (WPATH) – http://www.wpath.org/

American College of Pediatricians (ACP) – https://www.acpeds.org/

American Psychological Society (APS) – http://www.the-aps.org/

United Nations – http://www.un.org/en/index.html

Center for Disease Control – https://www.cdc.gov/

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