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One of the good things about doing a two parter is that you get the chance to receive feedback in the comments section on what you’ve said thus far. The last post was no exception, and an excellent discussion ensued in which some great points were made. But before I get to that, I’d like to have a bit of a meta-discussion, and set forth an editorial policy for this blog which will exist until otherwise rescinded. I like to show my commenters in the best possible light since they went to all the trouble of actually commenting, and thus I will take the liberty of making minor editorial corrections where it’s an obvious typo or mistake, if you really care about fidelity you can alway go back and read the original comment. With that out of the way let’s start with a comment from Mark:

From a sex perspective there is a difference, one of fundamental biology, in every cell of a person’s body – male vs female. This comes down to the definitional difference of sex versus gender. If you can’t agree that Jenner’s sex is fundamentally male, there’s nowhere to go from there. If we can agree on that, then it all boils down to the nebulous question, “what is gender?”

The general definition of gender is that it is socially, or potentially neurologically, constructed. If it’s a social conduct, it’s unclear what causes certain individuals to interpret their gender to be different from their biological sex based on cumulative social interactions. If it’s neurologically determined, we really have no understanding of the fundamental mechanisms involved.

Since we really don’t know what causes individuals to identify as a different gender, it’s a little premature to claim victory for one side of the argument that claims it is a natural phenomenon to be respected and accepted, over the side the claims it’s a condition to be treated. Both sides are arguing from the same degree of ignorance until we know what causes TG. Since we don’t even know whether it’s increasing our even increasingly identified, I try to be be a little less certain in my proclamations.

To begin with he makes a valuable distinction between socially constructed and neurologically constructed, a distinction which I mostly glossed over in the last episode. Also he makes a very valid point about certainty. I know that listing a bunch of theories, with my own sense of likelihood, isn’t the best way to demonstrate a lack of certainty, but I really am not certain about what’s happening, which I hope is somewhat reflected by my kitchen sink approach to the whole thing. Also, while it’s not exactly a theory, we should include in our list the very real possibility that we have no idea, that it’s something we haven’t even thought of, or that it’s a combination of a lot of things, many of which I may have touched on, some of which I almost certainly haven’t. All of this was not emphasized enough in the last episode.

Moving on, Boonton had this to say:

I suspect what is happening is probably akin to autism. On the one hand we know more about what to look for hence we see it more than we used too. On the other hand, the definition has been expanded so more are covered by it than they used to. However since we can’t measure past populations with today’s tests it’s hard to rule out if autism has remained constant, decreased or increased. I think we might get to a point where we could rule some things out. For example, I think we could rule out 0% from your days in HS. Might, though, the rate have been 1.5% and now it’s 2.5%?  

There might be something else afoot too…autism, like gender, is about how the individual relates to society and vice versa. Since society isn’t constant, this isn’t as simple as asking what the ‘rate’ is.

First, to clarify, I never claimed the rate at my high school was 0%. I claimed that there were zero individuals who were openly transgender, but that if I had to guess there were probably a couple who were closeted, which would be a rate of around a tenth of a percent. A number I’m sure Boonton and I disagree on, but I’m not trying to pull a there are no homosexuals in Iran stunt. Also as I indicated, I was more offering it up as a story/example of how the phenomenon played out for me than as actual hard data.

Second, I agree that autism is a pretty good analogy, particularly insofar as it speaks to a phenomenon where everybody agrees with Boonton’s point that part of the increase is due to being able to identify it better, while also expanding the definition of what it is. This all stems from the fact that there’s no blood test, brain scan, or other objective test for autism. It all depends on how closely the individual being screened for autism matches the criteria in the DSM. TGNC is similar and thus it is entirely conceivable that the increase is all just due to an increase in identification and a broadening of definition. The question, then, is once we account for those two factors do they explain the entire increase? Or is there something left over?

My gut says that there is, for a couple of reasons. First, to use the example of autism, the rate continues to increase despite an awareness of the problems of overdiagnosis. Second there are studies which have tied autism rates to paternal age, premature birth, and toxins in the environment. All things which have been increasing recently. Still it would be nice if there was some clear objective standard for whether someone is definitely autistic or definitely transgender. And in a roundabout way this takes us to our final theory for the increase.

7- Gender dysphoria is a body dysmorphic disorder similar to anorexia and bulimia

If you do a search for this theory on the internet you’ll find that it’s a popular but very controversial explanation for gender dysphoria. Up until recently, the sense I got was that this was one of the main explanations for what was happening. And people were confident enough in it as an explanation that it led people like Paul McHugh, the Chief of Psychiatry at John Hopkins from 1975 to 2001, to shut down their their gender-identity clinic, which was only re-opened last year. An act which I think mirrors the arc of this theory. What was once one of the main explanations for TGNC, gradually came to be one of those things that people don’t bring up in polite society. It’s not hard to see why, the association is definitely negative, but more than that, it doesn’t offer any immediate solution even if you grant the connection. Anorexia and bulimia are notoriously difficult to treat, meaning there’s not some simple solution which then can easily be transferred over and tested on people with gender dysphoria to see if it works. Moreover to the extent anorexia and bulimia can be treated, we haven’t identified the underlying cause, meaning that what works has been more a matter of trial and error, than anything that gets to the root of the problem.

This inability to discover an underlying mechanism makes any connection between the two conditions speculative at best. But they both share the qualities of being something entirely unexpected from the standpoint of evolution, at least partially driven by culture, and apparently increasing. For many people it’s the evolutionary angle that’s the most interesting. Though there is a group of phenomena I mentioned in a previous episode which might help explain things. The phenomenon of supernormal stimuli, edge cases where trends which previously had an upper limit set by nature, are allowed to exceed those limits by technology, creating unexpected behavior with no survival value.

Along those lines, if you’ll permit me to digress into some fairly wild speculation. Historically the vast majority of people would have no examples of extreme masculinity or femininity, being limited to the narrow sphere of people they came in contact with in the local village. None of these people would have much in the way of access to fancy clothing, to say nothing of makeup or a hair stylist. The modern world has changed all that, and now we are confronted with extreme examples of both masculinity and femininity all the time. And by extreme we’re talking about the one in a million supermodel or athlete.  The kind of person our ancestors wouldn’t encounter in a hundred lifetimes. People have already drawn a connection between anorexia and bulimia and the constant exposure of young women to incredibly skinny models. Could a similar exposure to gender extremes have created gender dysphoria? Also, consider, going back to our historical example, the lack of fancy clothing and similar didn’t apply to nobles and interestingly enough, that is precisely where we see most of the examples of androgyny, and similar “gender-bending” behavior. As I said, it’s some fairly wild speculation, but not completely baseless either.

Here we arrive at the roundabout connection I mentioned earlier. Whatever you feel to be the similarities between anorexia and gender dysphoria (and you may think there are none). The former is at least easy to diagnosis objectively unlike autism. Which is to say, we have an example of an objectively diagnosable condition which modernity has definitely made worse, and if there’s a connection maybe the same applies to gender dysphoria, despite the difficulties of evaluating it in a similarly objective fashion. That said when considering the likelihood there is at least one way in which they are dissimilar. The growth rate in anorexia and bulimia peaked quite a while ago, and more recently it’s basically plateaued, while, as I pointed out, the TGNC rate appears to have spiked only in the last few years.

With the final theory out of the way (and remember it may be a combination of these theories, and it also may be none of them). It’s time to tackle the question of why it matters. If it were simply a matter of fashion, say the return of bell bottoms, or even if it was a full on epidemic of cross dressing, but lacked any additional desires for surgical changes, it might merit a mention in my podcast, but I certainly wouldn’t spend two whole episodes talking about it. Clearly, however, this phenomenon goes beyond just a change in labels. There is definitely something more going on, the question is what? For some people it’s enough to label the whole thing as unnatural, and depending on how broad you want to make the definition of that word, it almost certainly is, but I’m enough of a libertarian to not care if something’s unnatural if it’s mostly harmless. Thus the question is not whether it’s unnatural (which is difficult or impossible to answer) the question is whether it’s harmless? And here the answer appears to be “no”, and on this point I find myself deeply indebted to an anonymous individual who took the time to comment on the last episode:

I can say from experience that dealing with gender dysphoria is very stressful. I’ve frequently felt suicidal, and I haven’t even had to deal with bullying or any of the other stuff that people who are living an ‘out’ TG lifestyle have to put up with. There’s definitely more to the high suicide rate than just bullying.

Here he mentions the issue that eventually gets brought up in any discussion of people who identify as TGNC, particularly if you’re speaking about harm, the issue of suicide. A couple of the other commenters get deep into the weeds trying to determine exactly what the rate is, and if you’re interested in that I would urge you to read their discussion. But I think even those who are most strident in arguing for a lower rate than what you can find in the literature (also their might be some confusion between suicide attempts and suicides) would agree that TGNC individuals are at a significantly greater risk of suicide than the general population, and of course the question is why.

One of the most common explanations, is that the increased risk of suicide is due to bullying. In which case there’s no harm inherent to the TGNC identification itself, all of the harm comes from the ignorant people who surround the individual. Here is where you see why I’m so indebted to the anonymous commenter, because he provides a first person account that his gender dysphoria made him feel suicidal and it had nothing to do with the bullying. This is a point I’ve made in the past, though when I made it then I was looking at some statistics rather than a first person account. Specifically I was pointing out the fact that the suicide rate was going up, particularly among TGNC individuals, but that it was going up at the same time that society was becoming increasingly tolerant. Two trends that should have been inversely correlated were positively correlated.

Which brings me to one of the things I was hoping to accomplish with these two episodes. If we can agree that the suicide rate among TGNC individuals is higher than the general population, and if we can agree it’s not solely because of bullying or because society is becoming less tolerant. Then I assume that we can all further agree that if we could reduce that rate without any other unintended consequences that we would want to do that. Right? From this it more or less follows that if TGNC is increasing and we can figure out why it’s increasing and stop that increase we should do it. Correct?

In response to anonymous’ original comment I said:

I hope you won’t mind if ask whether you would take the opportunity to eliminate your dysphoria if that were an option? Say there was a drug you could take with minimal side effects. Or is it so much part of your identity, that despite it being “very stressful” you wouldn’t want to eliminate it?

To which he responded:

I would have it removed in an instant. I would give up anything else too, as long as I was assured that I would be happier afterward.

Which means we have at least one person who is actually experiencing gender dysphoria who would answer “yes” to that question, i.e. that if we can figure out why it’s increasing and stop it from increasing (or even reverse it) then we should.

Obviously a lot hinges on whether it’s actually increasing. If the rate is static, as many people assume, than regardless of suicide risk there may not be much we can do. (Absent something radical like gene editing, and this assumes it’s actually genetic.) It may be, as they say, part of the landscape. However, as I’ve repeatedly said, I don’t think that it is static, meaning, there might be things we can do or not do. And speaking of things not to do, when considering transgendered individuals and suicide, much has been made of the suicide rate after gender reassignment surgery. And in fact, in the previous episode on this subject I brought it up as evidence that merely doing everything possible to match the outward expression of gender to what the person felt like on the inside was not a surefire solution to depression and suicide.

In the course of revisiting the subject while working on this episode I did look for any rebuttals for this increase. And I came across an article on transadvocate.com. The article brings up some excellent points, but they are all related to the way things were interpreted, they don’t question any of the actual results. You are welcome to read it for yourself, but as far as I can tell the chief complaint they have with the interpretation is that there was no control, that these are people who suffered so strongly from gender dysphoria that they went through with surgery even in a time when it was still relatively new and taboo (1973-2003) and that as part of that the amount of societal backlash was severe. Thus first, an accurate interpretation would have to account for the greater “bullying” experienced by post transition individuals, and second you need a control group of people who felt equally strong dysphoria but who didn’t have the surgery, your control can’t merely be anyone who identifies as transgender regardless of the intensity of that feeling. (See here for something similar.)

Both of these points make sense. The study was done when gender reassignment surgery was still very new. And one would expect the backlash to be greater. (Indeed if you look at people closer to the end of the study the increase appears to vanish.) Similarly given how new the surgical option was, it would make sense that only those with the most extreme cases of gender dysphoria would have taken that option, and at that level it may map to an increased suicide risk regardless of whether they underwent surgery.

All that said, I think the main point remains. We have this idea of what will help TGNC individuals, more tolerance, surgery, greater acceptance, etc. And all of them essentially flow out of my first theory (and maybe the second). That basically there’s just this hump where tolerance lags behind reality, and if we can just get over it, TGNC individuals will be no more suicidal than anyone else. And while I agree that tolerance is important, in fact the most important thing with respect to our day to day interactions, society just keeps getting more tolerate without any corresponding decrease in the number of suicides. Also this skips over understanding whether the increase is just an increase in the number of people identifying as TGNC or if it’s an increase in the actual underlying rate.  Instead we skip over that understanding and move straight to the tolerance step, and often times then rush straight on to the surgery step. But as far as I can tell there’s no evidence this reduces suicidal ideation. The article may be right that it doesn’t increase it, but I haven’t seen any numbers claiming that it decreases it, which means our best case scenario is that it holds things constant, with the possibility still open that it makes things worse.

This takes me to the other potential harm I worry about, how all of this plays out with respect to children. An increasing number of children identify as TGNC, and the question of how to handle them is becoming acrimonious to say the least. From The Economist:

What is unforgivable is that children are caught in the crossfire. Soaring numbers are seeking help for gender dysphoria…If they are unlucky, what happens next will have more to do with an adult battle over identity than with what is right for them.

Gender reassignment is a momentous choice, since it causes irreversible physical changes and, if surgery is done to reshape the genitalia, perhaps also sterility. For gender-dysphoric children the clock is ticking, since puberty moulds bodies in ways no drugs or scalpel can undo. Waiting until adulthood to start the transition therefore means worse results.

Some clinics buy time with puberty-blockers, which suppress the action of sex hormones. But these may have harmful side-effects. Furthermore, most gender-dysphoric children will probably not become transgender adults. Studies are scarce and small, but suggest that, without treatment, a majority will end up comfortable in their birth sex, so treatment would be harmful. Unfortunately, no one knows how to tell which group is which. Yet some trans activists have thrown caution to the wind. Specialists who start by trying to help gender-dysphoric children settle in their birth identities, rather than making a speedy switch, risk being labelled transphobes and forced out of their jobs. Few are willing to say that some such children may actually be suffering from a different underlying problem, such as anorexia or depression.

That’s a long quote, but it covers a lot of ground. And since I’m basically out of time, the key point I want to draw your attention to is that most transgender kids to not grow up to be transgender adults. (In another article The Economist gives the number as 12-39%). Meaning that understanding what’s going on, determining whether it’s increasing and why, are becoming more and more important.

I don’t know what to do, or what’s going on. Or which if any of these theories is the correct one, or what to tell a parent who has a TGNC child, or what to tell my anonymous commenter. Though I definitely think he was on to something when he said this:

I’m glad you’re finding this interesting. I’m finding it nice to be able to talk about.

I also think it’s nice to be able to talk about it. And I think being able to discuss all possible theories without fear of being labeled a horrible person might be a good first step..

There will be no episode next week, I’m going to be travelling. I probably still could have done something, but I didn’t want it to be rushed. In light of that I will lay off the guilt for the week as well. No request for donations. But if a lack of guilt is what you were waiting for then go right ahead.