Transgender: Fact or Fiction?

by Alison Hudson
April 21, 2015

Transgender has become a hot topic in the media of late. From the success of shows like Transparent, to gossip column rumors about Bruce (for now) Jenner, to political debates over bathroom bills and civil rights legislation, transgender people -– those whose gender identity does not align with their birth-assigned gender -- are getting a lot of attention. Because transgender is a hot topic, everyone seems to have an opinion on it and, especially in places like op-Ed pages and blog comments sections, many self-appointed experts have been sharing what they view as the “facts” of being transgender with others. Not surprisingly, many of those facts are plain wrong.

Full disclosure: I am both a transgender woman and a skeptic.. As a trans woman, my own subjective experience is all I need to “know” about being transgender. But as a skeptic, I was compelled, even before I started my gender transition, to learn as much as I could about what the sciences – be it psychology, neurology, biology, or sociology – had to say about transgender people. If I hadn't found answers that satisfied my skeptical nature, I may have handled my feelings differently. But when my subjective experience and the best information I could find in the scientific literature fell into sync, I knew I was on the right path.

As I have always enjoyed Skeptoid's “Fact or Fiction” episodes, I thought this would be a perfect opportunity to write one. You know the drill. I'll read off some common beliefs that people have about being transgender, and you get to guess: is it fact? Or fiction?

[A quick note about terminology: you'll hear me place people into two subgroups, “trans” and “cis”. “Trans,” of course, means transgender people. “Cis” is the opposite of trans – it's a convenient label meant to designate people whose gender identity is congruent with their birth sex. Basically, if you're not trans, you're cis.]

Let's begin with a popular one.

Being transgender is a mental illness

Fiction. There's no reputable medical authority in the world that considers “being transgender” a mental disorder.

In the United States, the main authority on what is and isn't a mental disorder is the American Psyciatric Association's Diagnostic and Statistical Manual of Mental Disorders, or DSM. As of the DSM-V, published in 2013, the condition most closely associated with being transgender is “gender dysphoria,” defined as “the distress that may accompany the incongruence between one's experienced or expressed gender and one's assigned gender.” The DSM further clarifies that “gender nonconformity is not in itself a mental disorder.”

Globally, the standard of mental disorder diagnosis is the World Health Organization's International Classification of Diseases, also called the ICD-10. The ICD-10 more or less matches up with the DSM on gender dysphoria, though some of the specific terminology is different; they still use the older designator “gender identity disorder”.

The important point here is that it's not the gender identity that's the problem; it's the distress caused by not being able to do anything about it. That's why gender transition is considered the most effective treatment for gender dysphoria: because it addresses not the identity, but the incongruity between identity and society.

Transgender people have brains like those of the opposite gender

Fiction, though don't take that to mean that trans brains are the same as their birth-assigned gender, either.

On the one hand, a study from 1997 did find that in trans women, a certain sexually dimorphic structure of the brain, the bed nucleus of the stria terminalis, matched the size and nerve density of the bed nucleus in cis women. Further, a 2008 study looked at another sexually dimorphic brain structure in trans women, the hypothalamic uncinate nucleus, and determined that this structure also matched the biology of cis women.

On the other hand, both a 2009 and a 2015 study found that the grey matter in most areas of trans brains matched the volume of grey matter in birth-assigned gender. A 2010 study of the brain's white matter also found that trans brains were not quite in the normal range for either cis men or cis women, but had some attributes of both.

Various studies like this crop up regularly, each one measuring some small brain structure or function, some of them leaning one way, some the other. But the fact is that they're all relying on small sample sizes and they're almost always single studies that have not been repeated. There's a surprising amount of science on this, but in the end a lot of it is inconclusive. Brains are far too complex to oversimplify with the idea that trans brains fit into one box or the other … or even that there are only two boxes to fit into.

More importantly, all of this is talking about measured averages of the physical brain, not the confluence of thoughts and experiences that make up identity. Just because one doesn't have the brain of the opposite gender does not mean one cannot have the mind of the opposite gender, or a mind that identifies as both genders, or as neither. Identities are just as complex as brains.

Transgender people often present unrealistic stereotypes of the gender they identify with

Mixture. It can be true, at least sometimes, but not for the reasons you think and not as true as it used to be.

Undergoing a medically supervised gender transition requires the approval of therapists and doctors, those who control access to hormones and surgery. In the trans community, these professionals are referred to as “gatekeepers” who stand between many trans people and the treatment they need. Gatekeepers decide who gets treatment and who doesn't, and for many decades it was the gatekeepers who demanded that trans patients could only access medically supervised transition if the patients were either very girly (for trans women) or very manly (for trans men), and if they stood a chance of “passing” as cis in society. Trans people basically learned to game the system so that they could get the medically necessary treatments they needed, and that often meant playing up gender stereotypes.

Thankfully, things are getting better. Doctors and therapists are letting go of these very stereotyped standards, and so trans people can access treatment without having to play up the stereotypes. Moreover, a growing number of trans people don't even identify as “male” or “female,” instead taking on gender nonconforming identities that defy cisgender stereotypes; these individuals can now also access treatment and surgery if needed.

A trans person's gender is determined by their chromosomes

Fiction. Your chromosomes determines your primary and secondary sexual characteristics, what is referred as “biological sex” – things like genitalia, body hair, breast development, and what hormones your body produces at puberty. The chromosomes do not determine your learned behaviors, do not declare whether you should wear a skirt or a necktie to work, and most definitely do not decide whether you ought to be called “sir” or “ma'am” at the service counter of the JCPenney; all of that is determined by your identity, your gender.

The easy way to remember the difference between “sex” and “gender” is this: sex is what is between your legs, while gender is what is between your ears. Chromosomes determine one; they most certainly do not determine the other.

Transgender people are more likely to suffer from depression and anxiety, even after transition

Fact. Comorbidity with certain mental disorders is a known and real issue for trans people, who are more likely than the general population to suffer from depression, anxiety, and even suicidal ideation. These issues can continue even after one transitions their gender identity. But like the chicken and the egg, it's a question of which comes first? Does dysphoria cause depression and anxiety? Do depression and anxiety trigger dysphoria? Or is something else going on?

As with the brain itself, the way the mind manifests mental disorders is complex and therefore the answer isn't 100% clear. However, in psychology there is a concept called “minority stress”. In short, it means that members of stigmatized minority groups face abnormally high levels of day to day stress, and that stress can lead to either manifestations of, or exacerbation of, conditions like depression and anxiety. Trans people live their entire lives in a transphobic culture that routinely delivers harassment, maltreatment, mockery, and discrimination. That isn't healthy. It's no wonder that depression, anxiety, and even suicide are constant issues in our lives.

Most transgender people undergo surgical transition

Fiction. Surgical transition is a blanket term for many procedures that trans people sometimes undergo to align their secondary sexual characteristics with their gender identities – not just the iconic gender reassignment surgery, or GRS, but also procedures such as mastectomies, orchiectomies, and facial feminizations. The truth is that many trans people have no surgeries whatsoever, while others elect only for minor procedures. Numbers are hard to come by, but it has been estimated that only about a third of trans people have sought out some sort of surgical transition.

The reasons for this are many. Some want surgeries, but can't afford them; in the United States, for example, various operations can cost anywhere from $5,000 - $40,000, and they are almost never covered by health insurance. Others may be able to afford surgical transition, but they dislike the cost and do not think that the benefits of surgery outweigh the risks. Still others don't want surgery; they're okay with their bodies or they're satisfied with less invasive methods of changing their gender presentation. There are many other reasons as well.

It's important to remember that being transgender isn't about getting surgeries. Genitalia does not equal gender. Regardless of how much or how little surgery a trans person has undergone, being transgender is about living one's authentic identity, however they choose to do it.

Hormone therapy and surgical transition are ineffective in treating gender dysphoria

Fiction. This statement is often prefaced by “A recent study from Sweden proved that … “ which is incorrect both in its use of the word “proved” to characterize a single study, and in the way it characterizes the actual findings of said study.

The study, which was indeed conducted in Sweden, found that trans people face ongoing minority stress, as described before, even after hormone therapy and surgical transition. It recommended to medical professionals that psychological counselling needed to continue even after surgical transition. The paper never called gender transition ineffective and it never, as is sometimes claimed, called for surgical transition to end.

And speaking of oft-repeated claims about the supposed ineffectiveness of surgical transition ...

Johns Hopkins Hospital, once a leading center for gender reassignment surgery, stopped performing the surgery because the surgery did not work

Fact, but a misleading one. Johns Hopkins Hospital was, in the 1960s and 1970s, a pioneering facility for GRS. And yes, in 1979 Johns Hopkins did cease performing GRS, and the reasons given did have to do with the perceived ineffectiveness of the surgery, as well as ethical concerns over amputating healthy organs.

However, that decision was largely made by one man, Paul McHugh, who was at the time Psychiatrist-in-Chief of Johns Hopkins. McHugh was, from the very beginning of his tenure, opposed to transgender as a legitimate condition. His crusade to end GRS at Johns Hopkins was waged primarily with questionable studies that he himself often oversaw. Johns Hopkins ended their GRS services because McHugh wanted them to.

So while the Johns Hopkins story is true, it's not legitimate as a measure of the viability of surgical transition or the validity of transgender identity. Using it as part of an argument is just an instance of cherry-picking in an attempt to fallaciously wield the authority of Johns Hopkins in the debate.

Transgender people are really no different than anyone else

Fact. Despite our perceived variance from social norms, the truth is we're just trying to live our lives, the same as anyone else. We have jobs, we buy groceries, we worry about the bills, we share cat videos on Facebook, and we have hopes, dreams, and desires that drive us. All we really want is a little bit of understanding and the same respect for our expressed gender identities as everyone else gets.

What trans people don't need is for those who are not trans to go around pretending that they're experts on our lived experiences. The facts are out there for those who choose to be informed, but they're rarely coming out of Internet comments sections or sub-Reddits. So the next time you see a cis person making definitive statements about those who are trans, it's a good time for you to be skeptical.

By Alison Hudson