Transgender

"Every day you're seeing our existence debated. Transgender people are so very real."

"If cisgender people, who are 99.5 percent of the population, are accused of transphobia for simply existing, failing to use the correct terminology, allowing genitals to influence their dating preferences, or even having non-queer Theory beliefs about gender, this is likely to result in much unfair antagonism against trans people (most of whom do not believe in this either)."

"Approximately 1 in 250 adults or almost 1 million adults in the United States identify as transgender. The frequency of adults, and especially younger adults, reporting a gender diverse identity has increased over time. Some persons who identify as transgender or gender-diverse (TGD) will seek treatment with gender-affirming hormones to align their bodies more closely with their gender identity. Medical treatment of people who identify as transgender improves body satisfaction, quality of life, and mental health. However, many of these treatments are not entirely reversible."

"Some adolescents or adults who take gender-affirming hormones subsequently elect to stop treatment. Most adults who stop gender-affirming hormones report doing so for reasons unrelated to a change in gender identity, such as pressure from family, difficulty obtaining employment, or discrimination. Also, discontinuation of gender-affirming hormones does not necessarily represent a failure in treatment or initial decision-making. Some TGD adolescents and adults who start and then discontinue gender-affirming hormones experience use of hormones as an important part of consolidating their gender identity and experience no regret over the use of hormones despite some permanent effects. However, a portion of TGD individuals who pursue gender-affirming medical or surgical affirmation do express regret over the permanent effects of treatment. In a metanalysis of 7928 TGD individuals who had gender confirmation surgery, 1% expressed regret after surgery. The most prevalent reason for regret was psychosocial circumstances, particularly from a lack of social support or negative reactions from family and employers."

"Clinical guidelines for medical affirmation of persons who identify as TGD suggest that the rate of “de-transition” among postpubertal adolescents and adults is rare, but few studies have assessed the actual rate of treatment discontinuation."

"Our study documented higher gender-affirming hormone continuation rates among transfeminine individuals and by patients who started hormones before reaching the age of legal majority in a population with universal insurance and access to low or no-cost medical and pharmaceutical care. Family socioeconomic status, family member type, and the official status of gender-affirming care as a TRICARE-covered benefit at the time the patient began taking gender-affirming hormones had no influence on continuation of gender-affirming hormones. We noted a higher hormone continuation rate among TGD individuals who were younger than 18 years old at the time of first use of gender-affirming hormones compared with those who were aged 18 years and older when starting hormones. This has not been documented in previous studies"

"This is probably one of the reasons why they are so successful in the discourse. It’s really easy to succeed when your point is simple and a lot harder when your point is complex. When you see someone like Ben Shapiro confront a college student and say, “Well, if I say I’m a moose, does that make me a moose?” or “biology is reality,” there is a very simple “logic” to what he says. But reality is complicated. It takes 10 seconds to say something that is wrong, but simple. And then it takes two minutes to explain something more complicated."

"One of the funniest things to me, the thing I cannot help laughing about really, is that people who look at the world and see women and men, when they’re going through that world, often they correctly gender trans people, and they can’t, in fact, carry out their ideological program. There’s this great clip of Ben Shapiro talking about Laverne Cox, and he correctly genders her by accident because he sees a world of men and women and he’s got fixed psychological categories. But Laverne Cox is in the “female” box in his head, and he has to try to forcibly pull her out of the female box in his head because he can’t help himself. A lot of these people can’t actually carry out their scheme because as you have mentioned in your writing, we don’t see people’s chromosomes. People suddenly say, “Oh, chromosomes are the end all, be all.” But that’s not, in fact, how the classifications operate. They are social categories."

"Sexual function and satisfaction in the transgender community is a nascent field with a paucity of data due to the fast paced nature of improving upon surgical technique and variety of patient experiences."

"Several factors, both mental and physical, must be considered when assessing for sexual dysfunction in TGDI prior to medical or surgical intervention as these factors contribute to one’s gender dysphoria. A systematic review of 44 studies analyzed data on sexual satisfaction, desire, arousal, orgasm, and pain. Generally, studies found that a healthy and positive relationship can have a positive impact on general sexual function, orgasm frequency and associated pleasure."

"Distress surrounding sexual activity or one’s own sexual health, which may or may not include individual anatomy, may impact general sexual satisfaction. Thus, those experiencing high levels of gender dysphoria may have lower levels of sexual satisfaction. Dissatisfaction with one’s body, or body dysmorphia can heavily contribute to sexual dysfunction and plays a large role in gender dysphoria. Specifically, one study of 141 trans men demonstrated a connection between body dysmorphia and difficulty with sexual arousal in 91% of participants."

"While there is not much data on sexual pain in trans men, one study found that 12% of 211 participants reported pain at the same frequency before and after genital reconstruction surgery."

"General sexual satisfaction has been shown to improve after initiation of gender affirming care, both medical and surgical. Several studies have shown a decrease in sexual distress after a combination of hormone therapy and gender affirming surgery. Interestingly some studies discussed a difference in sexual satisfaction based on the type of genital reconstruction that was performed, with one study showing an increase in sexual satisfaction for those who received a metoidioplasty compared to those who received a phalloplasty. Gender affirming surgery has shown to increase sexual satisfaction, even when solely analyzing body self image as demonstrated in several studies despite surgical complications."

"Most survey studies demonstrated an increase in ability to attain orgasm and an increase in intensity of the orgasm after medical and surgical transition. Data from these studies showed a 30% increase in ability to orgasm during sexual intercourse or masturbation after genital reconstruction surgery, not differentiating between metoidioplasty and phalloplasty."

"Several studies demonstrate a decrease in sexual desire after initiation of estrogen and antiandrogen medications. Prevalence of low sexual desire ranged from 32% to 73%, but the percentage of those experiencing distress from low sexual desire or hypoactive sexual desire disorder (HSDD) was 22% in a study of 214 trans women after medical and surgical affirmation. This distress associated with low sexual desire is a key marker for HSDD, a diagnosis often paired with depression."

"With regards to gender affirming surgery and its effect on sexual desire, most studies demonstrated an overall increase in desire compared to preoperative levels."

"Multiple studies have compared sexual arousal levels of trans women post-operatively with sexual arousal in cisgender women. In these studies, 90–100% of trans women reported experiencing sexual arousal post-operatively, but when level of sexual arousal was assessed using the Female Sexual Function Index (FSFI), sexual arousal scores were overall lower in trans women than in their cisgender counterparts."

"In trans women who have initiated hormone therapy, but who have not undergone genital reconstruction surgery, difficulty in achieving orgasm was seen to decrease. In one study, the prevalence of orgasmic dysfunction decreased to 29.2% from 46.7% after the initiation of hormone therapy. Whether this finding can be attributed to the simultaneous decrease in gender dysphoria and body dysmorphia associated with the initiation of hormone therapy still needs to be investigated. Ability to orgasm in trans women post-vaginoplasty has also been studied. Due to the unique anatomy of trans women post-operatively, it must be noted that orgasms can occur at multiple locations including the clitoris and prostate via masturbation or vaginal penetration, for example. There is variability in the rates of orgasm post-operatively with studies citing percentages between 40–100%. These studies used the FSFI to assess orgasmic scores and demonstrated ranges of 2.82 to 4.0 out of 6 in comparison to cisgender women without sexual dysfunction who scored an average of 5.1. When analyzing the correlation between sexual activity and achieving orgasm, one study found that direct stimulation of the clitoris had a higher frequency of orgasm when compared to intercourse. In assessing frequency and quality of orgasms post-operatively, studies are inconsistent. While one study reported an increase in orgasm frequency with sexual activity post-operatively, another study of 91 trans women postoperatively found orgasms to occur less frequently in 52.6% of participants and more frequently in 20.5% of participants. Quality of orgasms, when investigated, was found to be more pleasurable postoperatively in 51% of a 218 person study and with no changes in 62.5% of a 31 person study."

"Both medical and surgical affirmation care is improving with the overall goal of reducing gender dysphoria. Nevertheless, there are multiple areas for growth. Trans men and women undergo medical and surgical transitions in ways that affect sexual function and satisfaction. These sexual experiences can be directly correlated to gender affirming medical and surgical interventions. Overall, despite medical and specifically surgical complications, satisfaction with transition and sexual health is high."

"In January 2019, the Wall Street Journal ran my piece, "When Your Daughter Defies Biology." It provoked nearly a thousand comments, and hundreds of responses to those comments. A transgender writer, Jennifer Finney Boylan, quickly wrote a rebuttal in an op-ed that appeared two days later in the New York Times. Her op-ed garnered hundreds of comments and hundreds more reactions to those comments. All of a sudden, I was flooded with emails from readers who had experienced with their own children the phenomenon I had described or had witnessed its occurrence in their kids' schools - clusters of adolescents in a single grade, suddenly discovering transgender identities together, begging for hormones, desperate for surgery. . . . This is a story America needs to hear. Whether or not you have an adolescent daughter, whether or not your child has fallen for this transgender craze, America has become fertile ground for this mass enthusiasm for reasons that have everything to do with our cultural frailty: parents are undermined; experts are over-relied upon; dissenters in science and medicine are intimidated; free speech truckles under renewed attack; government healthcare laws harbor hidden consequences; and an intersectional era has arisen in which the desire to escape a dominant identity encourages individuals to take cover in victim groups."

"While some cisgender people refuse to take our experiences seriously, the fact of the matter is that transgender people can be found in virtually every culture and throughout history; current estimates suggest that we make up 0.2 – 0.3% of the population [or possibly more]. [...] In other words, we simply exist."

"Accusations that IP is inherently “narcissistic” and “divisive” have become quite prevalent among EC-centric leftists lately. [...] In addition to disregarding all forms of non-EC marginalization, accusations that IP activism is inherently “narcissistic” or "divisive" severely confuse cause and effect. After all, I’m not the one who is “obsessed” with my identity. [...] It’s the people who harbor anti-trans attitudes who are obsessed with my identity, not the other way around! While I would absolutely love to live in a world where my trans identity was not especially notable or worth calling attention to, these people insist on making an issue out of it. Furthermore, by making a distinction between transgender people (who they single out for discrimination) and non-transgender people (whose identities and experiences they respect), it is they (not us) who are the ones being divisive. Once we acknowledge this causality, it becomes clear that IP is not an expression of navel-gazing or narcissism, but rather a form of organized resistance against those who are actively trying to delegitimize and disenfranchise us."

"I would love to live in a world where the word “transgender” serves the same simple purpose — a mere sharing of information about my life experiences — but unfortunately, it doesn’t. On top of being a descriptor, the word “transgender” is also politically loaded. But that is not my, nor other trans people’s, fault. As discussed in the last section, there’s a long history of people hating, ostracizing, and criminalizing us, and much of this history took place before words like “transgender,” “transphobia,” and analogous terms even existed. In fact, those terms were created in response to that marginalization, not the other way around. And even if I were to relinquish my trans identity, those people would still exist and continue to discriminate against me for supposedly being a sinner, or freak, or deviant, or for being delusional, or whatever other rationales they might concoct in order to justify their bigotry."

"The most infuriating assertion regularly made by the "trans women are biologically male" camp is that trans people are somehow "denying" or "erasing" biological sex differences, and that this hurts cisgender women/“biological females.” This is patently untrue. I can assure you that trans people are highly aware of biological sex differences — the fact that many of us physically transition demonstrates that we acknowledge that sexually dimorphic traits exist and may be important to some people! I would reframe things this way: Transgender people often have a more complicated relationship with our sex-related traits (as they may be discordant with our identified and lived genders), and thus the language that we use to describe or discuss these traits may seem arcane, or nonsensical, or unnecessary to the average cisgender person. And because they are unfamiliar with this language (and/or flat-out antagonistic toward us), some cisgender people will subsequently misinterpret this language and differing perspective as some sort of "denial.""

"Experiences may vary. But again, humans are these overlapping bell curves. We, as trans people, have experience being members of both the male and female persuasions, and that relates to both physical and social aspects of gender. Having moved through the world as male and as female, we have very interesting experiences. And we have moved through the world as non-binary and have been read different ways and have experienced very real double standards."

"One of the things that really struck me during my transition—a lot of trans people have shared similar stories, but let me speak in “I” statements—one of the most startling things that I totally did not expect was that people who knew me before I transitioned were so invested in my being a he/him. Versus after I transitioned, and people started reading me as female, I would get the reverse situation—where people, upon finding out I was trans, were shocked. They were just as shocked to find out that I was trans, when I presented as a woman, as the people who knew me as male were shocked when I came out to them as trans. And so it’s very weird to be in a world where people just accept me as like she/her and nobody thinks about it. But then I’ll still have people from my past, who I don’t see all that often, who slip up and call me the wrong pronouns. And I think this is exactly what you’re saying. I think we have these boxes—I sometimes describe them as filing cabinets. Not like literal spaces in your brain, but basically, we organize people, or we’re taught to organize people, according to the man box or the woman box. And it creates difficulty for all of us, including myself."

"I think most trans people would say the same thing, which is that once you learn more about gender, about trans people’s experiences, when you learn about non-binary people, there are these hurdles or obstacles you have to get over. You have to think about the world in a slightly different way to accommodate people who exist, people you didn’t know existed in the world before. And I think all of us do it to some degree, even if it’s not about gender. Almost all of us grow up in a very straight world. We think there are men and women and husbands and wives, and those are the only relationships. And then as you get older, you realize that there are same sex relationships. And that’s a hurdle that a lot of us get over at a certain point in time. We realize that there’s more diversity here. And so it’s not any different with trans people. It’s just that as a society, most of society has moved on. Not all, obviously. I don’t know specifically what Ben Shapiro’s opinion is on same sex relationships. [Editor’s note: Shapiro has claimed homosexuality is a mental illness and a sin.] But I think most people have accepted same sex relationships. And trans is a new thing to them, even though trans people have been around forever."

"I would love to be at a point where—and obviously, we’ve taken this kind of backlash turn—we realize that trans people provide a lot of insight for everyday people about gender. People will debate the differences between the sexes, and it’s like, trans people have written about our experiences with, say, hormonal transitioning. And the answer is that yeah, there are very real differences. Experiences may vary. But again, humans are these overlapping bell curves. We, as trans people, have experience being members of both the male and female persuasions, and that relates to both physical and social aspects of gender. Having moved through the world as male and as female, we have very interesting experiences. And we have moved through the world as non-binary and have been read different ways and have experienced very real double standards. A lot of these anti-trans people purport to be feminists. I’m not going to say they aren’t feminists, but their feminism seems a bit off to me. We can talk at great length about how sexist double standards are very real things—if you would stop fighting us. There are a lot of feminists who appreciate trans people’s insights and perspectives into these issues. But this particular group of people, some of whom consider themselves to be feminists, just really don’t want to have that conversation. They only want to have one conversation, and it’s one where trans people don’t get to speak and where it ends with us being shown the door."

"So going back to the question of trans women are women or a woman trapped inside a man’s body, these statements from a transgender perspective very clearly are attempts to explain something really complicated in a very simple way to people who might not get it. I came up against the whole thing when I was first transitioning. What does it mean to be a woman trapped inside a man’s body?—which is never how I saw myself, but it was what I had to answer for the statement that other people would make. Growing up, I had no idea what other girls felt or what other boys felt. I had no idea; I only knew what I was experiencing. And so when I say I’m a trans woman, it’s not because I aspire to be a woman or have stereotyped notions of being a woman or that I’m making a crass assumption about what women really feel. I’ve no idea what anybody feels on the inside except me. There are some people who have really strong feelings. And you can say feelings—I would say it’s a little more complicated than that. I often describe it as being similar to cognitive dissonance, a kind of understanding that your body should be a particular way that it isn’t, and trying to sort that out."

"Matt Sharp, a top lawyer at ADF who drafts model legislation on the group’s behalf, said he expects issues dealing with transgender athletes and medical care to reach the Supreme Court. In an interview, Sharp compared judges ruling in favor of allowing gender-affirming care for transgender minors to courts upholding forced sterilization for disabled individuals a century ago. “I think it’s always worth stepping back and remembering the courts get it wrong sometimes,” Sharp said. “It was about 100 years ago that the Supreme Court upheld forced sterilization for individuals with mental disabilities. It was a wrong decision. And thankfully, both the courts and the medical community recognized the damage that they were doing to a vulnerable population and corrected that mistake. Similar here, these are courts that are struggling now.”"

"Paul Smith, who successfully argued the 2003 landmark Supreme Court case Lawrence v. Texas, which found the U.S.’s remaining sodomy laws unconstitutional, said the repeated victories for LGBTQ people and advocates are “a sign that these laws are mostly being thought up based on their appeal to a certain frenzied group of people in the country who were very excited about picking on LGBTQ people right now, not based on their legal merits and sustainability. “Take a law that says, you can’t have a drag show. It’s hard to imagine an easier First Amendment case to win, because it’s just plain content censorship,” he said. “And there’s not going to be any evidence that is harmful to somebody.” Smith, a professor at Georgetown Law, said the cases regarding restrictions on transition-related care are more complicated, but the wins still make sense, because in those cases the care is supported by the adolescents, their parents and doctors, and by expert testimony."

"It is difficult to generate a counterdiscourse if one is programmed to disappear. The highest purpose of the [medically defined] transsexual is to erase h/erself, to fade into the "normal" population as soon as possible. Part of this process is known as constructing a plausible history--learning to lie effectively about one's past. What is gained is acceptability in society. ... In the transsexual's erased history we can find a story disruptive to the accepted discourses of gender."

"To attempt to occupy a place as speaking subject within the traditional gender frame is to become complicit in the discourse which one wishes to deconstruct."

"Transsexuals for whom gender identity is something different from and perhaps irrelevant to physical genitalia are occulted by those for whom the power of the medical/psychological establishments, and their ability to act as gatekeepers for cultural norms, is the final authority for what counts as a culturally intelligible body."

"Fifty-three studies were included. Findings indicate reduced rates of suicide attempts, anxiety, depression, and symptoms of gender dysphoria along with higher levels of life satisfaction, happiness and QoL after gender-affirming surgery. Some studies reported that initial QoL improvements post gender-affirming surgery were not always enduring."

"There is a paucity of data regarding transgender and gender diverse (TGD) people who ‘‘detransition,’’ or go back to living as their sex assigned at birth. This study examined reasons for past detransition among TGD people in the United States."

"Among TGD adults with a reported history of detransition, the vast majority reported that their detransition was driven by external pressures. Clinicians should be aware of these external pressures, how they may be modified, and the possibility that patients may once again seek gender affirmation in the future."

"Of all respondents who reported a history of detransition, 82.5% cited at least one external factor. A total of 15.9% of respondents cited at least one internal factor. Of all participants who ever pursued gender affirmation, 10.8% reported lifetime history of detransition due to an external factor and 2.1% reported a lifetime history of detransition due to an internal factor."

"Older age cohorts were more likely to report a history of detransition due to caregiving responsibilities, or pressure from a spouse or partner. Younger age cohorts were more likely to report a history of detransition due to pressure from a parent, pressure from the community or societal stigma, and pressure from friends or roommates."

"In this national study, 13.1% of TGD respondents who had ever pursued gender affirmation reported a history of detransition. To our knowledge, this is the first study to systematically examine reasons for detransition in a large national sample of TGD adults. The vast majority of participants reported detransition due at least in part to external factors, such as pressure from family, nonaffirming school environments, and sexual assault. External pressures such as family rejection, school-based harassment, lack of government affirmation, and sexual violence have previously been associated with increased suicide attempts in TGD populations. Our findings thus extend prior studies, and suggest that external pressures should be understood not only as risk factors for poor mental health but also as obstacles to safely living in one’s gender identity and expression."

"A history of detransition was significantly associated with male sex assigned at birth, consistent with prior research, indicating that TGD people assigned male sex at birth experience less societal acceptance. Detransition was also significantly more common among participants with a nonbinary gender identity or bisexual sexual orientation. These findings are congruent with past studies, indicating that TGD people who identify beyond traditional binary and heteronormative societal expectations are less likely to access gender-affirming services."

"Lack of family support was also associated with a history of detransition, which is of particular concern, given the strong association between familial nonacceptance and suicidality."

"[G]ender affirmation is a highly personal and individualized process, and not all TGD people will desire all domains of gender affirmation at all times, as has been highlighted in case literature regarding people who desire medical but not social affirmation."

"It is important to highlight that detransition is not synonymous with regret. Although we found that a history of detransition was prevalent in our sample, this does not indicate that regret was prevalent. All existing data suggest that regret following gender affirmation is rare. For example, in a large cohort study of TGD people who underwent medical and surgical gender affirmation, rates of surgical regret among those who underwent gonadectomy were 0.6% for transgender women and 0.3% for transgender men. Many of those identified as having ‘‘surgical regret’’ noted that they did not regret the physical effects of the surgery itself but rather the stigma they faced from their families and communities as a result of their surgical affirmation. Such findings mirror the qualitative responses in this study of TGD people who detransitioned due to family and community rejection."

"Although there have been published guidelines for gender affirmation, case studies regarding detransition, and published data on the uncommon experience of regret following gender affirmation, there has been little rigorous study with large TGD community samples regarding detransition."

"“The laws do so much damage when they’re passed that I think it’s difficult to see even the court victories as a good thing on balance,” said Ryan Thoreson, a University of Cincinnati law professor and former researcher for Human Rights Watch. “The sheer number of these laws has been significantly disruptive to the care that transgender children are receiving. They’ve had a chilling effect on providers who are now much more cautious about providing some of these services to kids and their families.”"

"In this prospective clinical cohort study of TNB youths, we observed high rates of moderate to severe depression and anxiety, as well as suicidal thoughts. Receipt of gender-affirming interventions, specifically PBs or GAHs, was associated with 60% lower odds of moderate to severe depressive symptoms and 73% lower odds of self-harm or suicidal thoughts during the first year of multidisciplinary gender care. Among youths who did not initiate PBs or GAHs, we observed that depressive symptoms and suicidality were 2-fold to 3-fold higher than baseline levels at 3 and 6 months of follow-up, respectively. Our study results suggest that risks of depression and suicidality may be mitigated with receipt of gender-affirming medications in the context of a multidisciplinary care clinic over the relatively short time frame of 1 year. Our findings are consistent with those of prior studies finding that TNB adolescents are at increased risk of depression, anxiety, and suicidality and studies finding long-term and short-term improvements in mental health outcomes among TNB individuals who receive gender-affirming medical interventions. Surprisingly, we observed no association with anxiety scores. A recent cohort study of TNB youths in Dallas, Texas, found that total anxiety symptoms improved over a longer follow-up of 11 to 18 months; however, similar to our study, the authors did not observe statistically significant improvements in generalized anxiety. This suggests that anxiety symptoms may take longer to improve after the initiation of gender-affirming care. In addition, Olson et al found that prepubertal TNB children who socially transitioned did not have increased rates of depression symptoms but did have increased rates of anxiety symptoms compared with children who were cisgender. Although social transition and access to gender-affirming medical care do not always go hand in hand, it is noteworthy that access to gender-affirming medical care and supported social transition appear to be associated with decreased depression and suicidality more than anxiety symptoms."

"Our study provides quantitative evidence that access to PBs or GAHs in a multidisciplinary gender-affirming setting was associated with mental health improvements among TNB youths over a relatively short time frame of 1 year. The associations with the highest aORs were with decreased suicidality, which is important given the mental health disparities experienced by this population, particularly the high levels of self-harm and suicide. Our findings have important policy implications, suggesting that the recent wave of legislation restricting access to gender-affirming care may have significant negative outcomes in the well-being of TNB youths. Beyond the need to address antitransgender legislation, there is an additional need for medical systems and insurance providers to decrease barriers and expand access to gender-affirming care."

"Testosterone use among transgender people likely impacts their experience of sexual function and vulvovaginal pain via several complex pathways. Testosterone use is associated with decreased estrogen in the vagina and atrophic vaginal tissue, which may be associated with decreased vaginal lubrication and/or discomfort during sexual activity. At the same time, increased gender affirmation through testosterone use may be associated with improved sexual function."

"Testosterone use among transgender men and gender diverse people was associated with an increased interest in sexual activity and the ability to orgasm, as well as with vaginal pain or discomfort during sexual activity. Notably, the available evidence demonstrates that >60% of transgender men experience vulvovaginal pain during sexual activity. The causes of pelvic and vulvovaginal pain are poorly understood but are likely multifactorial and include physiological (eg, testosterone-associated vaginal atrophy) and psychological factors (eg, gender affirmation)."