Gender Identity, Biological Sex, and Psychopathology: Back to Basics
The following post is adapted from the answers I gave to J.D. Haltigan in a Q&A we had for his substack, The Multilevel Mailer. In these answers I clarify how I think about the relationship between gender identity and biological sex and why I resist seeing trans identity as psychopathological or as a denial of biology.
When do differences in developmental trajectory become disordered? This is not simply an empirical matter. Some cases are quite clear because there is broad consensus, but other cases are not, and even scientists who are interested only in empirical and quantitative questions cannot ignore the value disagreements involved. We can study “autism,” for example, an empirical phenomenon—its epidemiology, causal mechanisms, evolutionary history, etc.—just as we can study homosexuality as an empirical phenomenon, but that doesn’t by itself determine what our clinical attitude towards this condition should be. Questions of psychopathology are, in my view, fundamentally questions about the appropriate clinical attitude we should adopt towards a behavioral phenomenon.
It’s inevitable for the practice of medicine and psychology to be colored by social prejudice to some degree, and I think our notions of psychopathology are particularly vulnerable. This isn’t to say that most of what we call psychopathology is simply a reflection of social prejudice. I don’t think that is the case. But because this vulnerability exists, we have the responsibility to guard against it. Homosexuality is the clearest historical example. Paraphilias, asexuality, transgender identity, autism are all conditions where social evaluative judgments become quite relevant. And I think social attitudes matter a great deal for some cases of “voice hearers,” certain personality styles (e.g. schizoid or schizotypal), grief, cases of substance use, temperamental styles (e.g. hyperthymic), etc. And I think the best way to do that is to have an open discussion about why something is a problem, for whom it is a problem, and to have a democratic dialogue between the stakeholders about the value judgments and practical needs involved.
The empirical aspects of diagnosis have to be settled via scientific inquiry. However, facts about causal mechanisms don’t determine whether we see the condition as problematic or undesirable, the contexts in which the condition comes to clinical attention, and decisions regarding whether we should try to change the person or the environment around them, whether our attitude needs to be one of acceptance, accommodation, or cure, and whether we should pay for the care involved through money devoted to healthcare needs. There is no naturalistic boundary between psychopathological and normative psychological functioning. We are drawing lines on a continuum without natural discontinuities, and we have to be mindful of the goals our thresholds and distinctions are intended to achieve and the value disagreements around these goals.
When it comes to gender identity, the use of pronouns, and the binary nature of sex, I fail to see why our language and identity should be constrained by any particular biological understanding of sexual differences. “They/them” pronouns are not claims about the nature of sexual differences as they arise in evolution. Their use is fundamentally about how we relate to ourselves and others in a certain social context, and what we want to communicate to others and what we want others to acknowledge about us. Pronouns are not intended to be empirical representations of one’s physiology that can be falsified by scientific research. To think so is to misunderstand the nature of pronouns and gender identity. I do think it is a problem if any movement aimed at social justice rests on a rejection of established science, but I don’t think that’s what’s going on here. It only seems that way because we are treating notions of “psychopathology” and “gender” as if they were empirical facts.
I am skeptical that there is an “essence” to biological sex… physiology at the time of birth doesn’t have some special, immutable status.
I am skeptical that there is an “essence” to biological sex or that biological sex is immutable. It is true that at the time of birth we possess certain physiological characteristics that generally correspond to certain trajectories of sexual development. It is also the case that these trajectories demonstrate sexual dimorphism. Crucially, there is considerable variation within and considerable overlap between the sexual categories, and there are also various intersex phenomena. Given advances in medicine, humans are also in a position to intervene on this trajectory of sexual development. We can modify our biological characteristics, and in the context of such malleability, physiology at the time of birth doesn’t have some special, immutable status.
Over the course of human history, dimorphic social roles developed around our sexually dimorphic developmental trajectories, but social roles are subject to even greater variability and malleability. A psychological sense of oneself being a man, woman, or neither, exists at this interaction of physiology and society. I am sure there is some biological underpinning, so to speak, to a persistent psychological experience of identifying as a man/woman/non-binary, but I don’t think the idea of “brain sex” does justice to the complexity of what is involved, especially if the notion of brain sex invokes essences and immutability.
It is in this context that we have to tackle the issue of a person’s subjective identity not being aligned with the particular physiological characteristics that they were born with or that they currently possess. Gender identity is different from notions of masculinity and femininity in this regard. There are many masculine women or feminine men who continue to think of their identities as women or men respectively and have no desire to transition. It is up to us to determine what our attitudes towards gender incongruence should be, and I think our attitude should be one of inclusivity and acceptance. Pronouns are linguistic and social tools, not representations of sexual physiology. While previously we could only modify social roles (and there is a long history of people living their lives as members of the opposite sex), now we also have the means to modify sexual physiology.
Pronouns are linguistic and social tools, not representations of sexual physiology.
The idea that some gender identities are “real in biological sense” and others are not is quite problematic. It’s not like we can point to an area of the brain or the activity of a brain network and say, “this is where gender identity is.” What we have are various aspects of physiology that reflect a particular trajectory of sexual development, and then we have a more complicated subjective sense of who we are in relation to our physiology and the gendered social norms. Social gender categories are not direct and inevitable expressions of one’s physiology. That was true even in the past, but it is especially true in an age when we have the means to modify our physiological characteristics. Why is it that some people’s psychological sense of who they are is at odds with their bodily and hormonal physiology? We don’t know, and neuroscience hasn’t advanced enough for us to offer an account of identity in neuroscientific terms. Transgender identity is a state of misalignment between a person’s internal, personal sense of their own gender and the identity we’d typically expect that person to have given the particulars of their neurophysiology on birth. Our clinical and social attitude towards this misalignment is up to us. Neurophysiology and evolutionary history do not determine what we ought to do.
To the extent that judgments of pathology and psychopathology reflect our clinical and social attitudes towards a particular state of being, they are socially constructed, and to the extent that judgments of pathology and psychopathology reflect neurophysiological or evolutionary empirical facts, they do not determine our clinical and social attitudes (even though they are certainly relevant). This is, in one sense, an ethical question: How should we—as individuals and collectively as society—approach people with transgender identity? What can we do to alleviate their dysphoria and enhance their well-being?
Affirming people’s gender and ensuring they can transition successfully is a far better strategy, in my opinion, than forcing people to live with their dysphoria. Similar logic applies to homosexuality, where the case for socially accommodating the sexual difference is far stronger than trying to change the sexual orientation. In contrast, we have good ethical and social reasons to not accommodate states such as pedophilia. Evolutionary biology provides us with hypotheses and facts related to our evolutionary history. It doesn’t tell us how things ought to be. Evolutionary design is not synonymous with health. Our notions of health, well-being, and psychological flourishing are not determined by facts about our evolutionary history, although they are informed by it.
As a clinician and psychiatrist, I am in general agreement with the model of gender affirming care. We would be abdicating our Hippocratic mandate if our response to trans-suffering was to deny trans people gender-affirming healthcare. The suffering of those who detransition matters; we shouldn’t ignore it, we should discuss it openly and we should ensure that relevant facts are available to individuals and families who are deliberating on transition. But detransition is uncommon enough that it doesn’t justify, in my opinion, broad restrictions to gender-affirming healthcare.
There are folks who see transgender identity as arising from some combination of personality psychopathology, social contagion, and developmental vulnerability, such that vulnerable individuals are buying into a story they belong to the opposite gender, and this leads them down the path of gender transition and medical interventions that eventually hurt them rather than help them. And if that were the case, our response should indeed be one of alarm and concern, with steps taken to protect the youth. But based on my own clinical experience (in a general psychiatric setting rather than one specializing in gender affirming care), my interactions with trans individuals, and my familiarity with the clinical and scientific literature, I don’t have reason to believe that this personality psychopathology plus social contagion story is applicable to vast majority of trans individuals. I wouldn’t say it applies to no one; the fact that some people do de-transition and express regret over medical treatment lends some support to it. But as far as I know, vast majority of people whose gender dysphoria is persistent and severe enough that they seek out puberty blockers, hormonal treatment, or surgical treatment have stable trans-identities. It is not a “phase” that they grow out of. People often focus on developmentally vulnerable adolescents, but then they extend the same skeptical attitudes even towards adults who have had stable trans identities for years and decades.
Much of the medical debate (e.g. Cass report) revolves around the quality and strength of the research evidence in support of medical interventions such as puberty blockers in youth. Saying that available evidence is uncertain or low quality by some standards (Cass Report: “not enough is known about the longer-term impacts of puberty blockers for children and young people with gender incongruence”), standards which are themselves subject to debate, is different from the conclusion that we should treat trans-identity as a pathology or that gender-affirming care by and large hurts people. The totality of evidence, which includes clinical trials as well as the testimonies of trans individuals, suggests that trans individuals indeed benefit from gender affirming care. Uncertainty around the strength and quality of evidence is not a sufficient reason for these interventions to be legally restricted.
Puberty blockers and hormonal treatments have risks, but so does puberty for transgender and gender non-conforming youth. How to choose between these risks is a deeply personal decision.
All individuals contemplating gender-affirming treatments should have adequate opportunity to reflect on the options available to them and be informed of all the risks of hormonal treatment and surgical interventions, including available data about detransition and uncertainties around evidence. No one should be rushed or forced into medical treatment. I think it is cruel to force children to undergo the physical changes of puberty that are unwanted and that cause them intense emotional distress. Puberty blockers and hormonal treatments have risks, but so does puberty for transgender and gender non-conforming youth. How to choose between these risks is a deeply personal decision and I agree with the American Psychiatric Association position statement:
“For gender diverse youth and their families, decisions to which gender-affirming medical, surgical, social, and/or legal procedures to pursue are best managed via an informed consent approach.” (American Psychiatric Association, 2020)
Caution is indeed warranted. Puberty blockers and hormonal treatment aren’t things that anyone should take lightly. We should make efforts to ensure that individuals will not later come to regret this, but eventually we have to confront the fact that trans-identity and gender non-conformity are neither transient fads nor a result of emotional immaturity and psychological confusion. And the most ethical and least harmful response in my view is to support access to affirming and supportive treatment for trans and gender diverse youth and their families, including puberty suppression and medical transition support, even as we debate the strengths and weaknesses of the research evidence and even as we take detransitioners seriously.
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Thank you for this. You have described my thoughts about gender-affirming care, but far more eloquently than what I could have written. As a father and caregiver for my adult transgender daughter, who also has a psychotic disorder, a transition in gender identity is just one more parenting experience that I did not anticipate. But if I look back on my daughter's childhood, I do recall her preference for activities that are stereotypically associated with females--she has always enjoyed cooking and writing. She wanted us to read her Nancy Drew books as a child, rather than Hardy Boys book series. She never enjoyed playing or watching sports, working with tools, or other typical boy activities. Maybe these preferences are irrelevant given the diversity of human interests, or maybe not. It was years later, as a 22-year-old adult, that she expressed her desire to identify as a woman. My daughter is clearly happier and her personal hygiene is much better since she changed her gender identity. She is now 27 and is being treated with testosterone blocker and estrogen by her primary care physician.