Genetics, Gender Identity, and Youth Transitions: Context and Questions for Reflection

by Mauro Sifuentes, doctoral candidate in Education & community-based educator

During late July this past summer, Stephen Rosenthal, M.D., medical director of the UCSF Child and Adolescent Gender Center, a professional collaborative of medical and advocacy experts, presented recommendations to a group of over a hundred parents of transgender youth who showed up to hear the most recent findings from a field of research that seeks to identify a biological basis for transgender identities; most of the adults present were parents of children or youth who receive clinical care from this center. Dr. Rosenthal is a professor of pediatrics at UCSF who specializes in pediatric endocrinology and who has served as a consultant for pharmaceutical corporations who develop and market hormones and hormone blockers. On this particular day, he was attempting to address parents’ concerns regarding difficult decisions they may have to make, or have already made: the choice to give consent for their children’s bodies to be altered through puberty blockers and hormone therapy.

The presentation was part of a weekend-long conference hosted by Gender Spectrum, a Bay Area-based education and advocacy non-profit, that prioritizes “gender sensitive and inclusive environments for all children and teens.” The conference, which attracts families, presenters, and participants from all over the Bay Area (and some traveling much longer distances to attend), provides a unique meeting place for medical and mental health professionals, educators, advocates, youth, and parents. For some participants, including youth, this conference is their first time speaking openly with others who may have similar experiences navigating the terrain of transgender identities, and the challenges that come with it. The annual Gender Spectrum conference grew out of a need to break the isolation of parents who are made to face difficult decisions in a world that is only growing incrementally more hospitable for transgender children and youth, and hardly so for those who appear more androgynous or do not live in supportive communities or families.

One of these particular challenges falls on parents, and their decision-making power over their children. While it is still portrayed as a controversial choice for an adult to decide to medically transition genders, often through hormones and surgeries, it is an even more contentious choice when parents are making life-changing decisions about their children’s access to hormones or surgeries. Because of the stigma often attached to making such a choice, Dr. Rosenthal’s presentation may help lessen parents’ concerns about whether or not they are making the right choice in moving ahead with either puberty blockers (which block the hormones that will lead to the puberty of sex-assigned-at-birth) or so-called cross-sex hormones (which promote the development of secondary sex characteristics associated with the gender with which a child identifies or resonates). However, presenting research in an attempt to prove a biological basis for transgender identities has been met with mixed responses.

Dr. Rosenthal is one of the pioneers in this controversial field of transgender pediatric and adolescent health, and work like his has come under criticism from peers in the medical field, as well as from another unlikely group of critics – transgender people themselves, in addition to intersex, de-transitioned adults, and non-binary people who identify as neither male nor female. These groups of people worry that hormones and surgeries will be used to mask young people’s queer and transgender identities, and gender diversity more broadly. Many transgender people choose to live without medical interventions on their bodies. Intersex adults – people who cannot or should not be classified as male or female – often have experienced the long-term consequences of adult decision-making power over their bodies and genders, and do not want others to have that choice taken away. There is also a growing movement of adults who medically transitioned genders before the age of eighteen who now call themselves “de-trans” and believe they were coerced into making decisions that were not appropriate for them, while others believe that medical gender transition was appropriate for them at the time, but that their gender identity has shifted again in late adolescence or adulthood. Non-binary adults are people who may pursue medical gender transition, but who do not necessarily identify as either male or female. These diverse stakeholders are often skeptical of early medical interventions on children’s bodies and identities, particularly when the primary goal is to secure a “normal” life, a goal that often feeds unrealistic expectations resulting in long-term negative consequences, such as depression, or, a lack of connection to queer communities as an adolescent or adult.

These groups have voiced concerns about the drive behind the search for a genetic basis for transgender identities, drawing upon lessons learned from the now-discredited “reparative” therapies for intersex, gay, lesbian, bisexual, and queer youth and adults that sought to “correct” and erase queer genders and sexualities during times of intense stigma, including today. In addition to stigma, laws were crafted in the 19th and early 20th centuries that made it illegal to wear clothes of “another sex” or to engage in homosexuality. Interestingly, and of concern to those who have studied the covert reinventions of eugenics, California reformers who were interested in white racial purity also became interested in how mothers and fathers, in their portrayals of polarized masculinity and femininity, could craft “fitter” children that would prevent the degeneracy of the white race.

Lewis Terman was a leading figure in the California eugenics movement who invented and popularized the Stanford-Binet intelligence test, a tool used to assess “feeblemindedness” and identify young people for forced sterilization. Terman also developed the “M-F” test, which was used – and to some extent is still used – to predict homosexuality and gender diversity in youth and young adults, and to channel them into so-called reparative therapies to prevent the further development of diverse genders and sexualities. Here, we can see that the impulse to draw clear lines around racial groupings is intimately linked to the desire to have clear lines between male/female, even as standards for men and woman are often in flux, changing across time and place. Many advocates for transgender youth – including transgender adults – feel pressure to justify challenging and controversial decisions, often relying on research that reproduces a certain logic known to harm the very interests of people they seek to support.

And yet, the research seeking a genetic basis for transgender identities is forging ahead. A team of international researchers from the U.S. and Europe have already begun to collect DNA samples from thousands of transgender people in an effort to identify genomic markers that could be used to predict the development of transgender identities, something researchers themselves have inadequately defined because they are not trained in gender or cultural studies. As this work develops, we must continue to ask ourselves questions about what ethics and understandings are driving this research, as well as all the potential outcomes and consequences for transgender children and youth, many of whom are often making decisions in a crucible of medical and psychological experimentation, binary gender coercion, inconclusive data, misinformation, and immense discrimination. Even with the good intentions of parents, and physicians like Dr. Rosenthal, without a more robust discussion that puts the interests of transgender children, youth, and adults in a larger social and historical context, we may be repeating missteps of the past. These important deliberations would benefit from refusing simplistic resolutions, and instead, foregrounding the priorities and needs of diverse children, youth, and families, rather than physicians and researchers.

I am someone who made the difficult and complex choice to pursue medical gender transition as an adult. As a youth advocate who has been blessed to know many self-actualized young people who are intelligent and capable enough to make decisions about their own bodily self-determination, I am also not advocating that these options be taken away from youth. Instead, I would ask that we ask under what circumstances, in which kinds of communities, and with what support are young people seeking clinical psychological and medical care that helps them explore new possibilities for gender? They are not sick, unfortunate, helpless victims of a psychiatric condition. How do we come to see youth not as overly genetically pre-determined, but as creative individuals embedded within cultural contexts that shape life’s possibilities, and that many of these possibilities – or constraints – warrant expansion or resistance? So much of my process was shaped by the ways I’ve grown through queer communities, and how I’ve been supported in making sense of gender, sexuality, family, and community in queered ways because of this cultural embeddedness. All youth, regardless of whether or not they identify as both trans and queer, deserve to know about alternative ways to craft a sustainable, meaningful, and supported life, beyond clinical diagnoses and solutions. Our world today needs more creativity around gender, not less.

Trans Surgery, Life-Saving Surgery, and the Space Between

by Mauro Sifuentes, doctoral candidate in Education & community-based educator

I have been under general anesthesia five times in this life. The first time, I was three and had a hernia repaired; because the anesthesiologist didn’t want to over-medicate me, I ended up waking up before the surgery was over. One of my earliest memories is trying to lift up my head – which felt incredibly heavy – and looking down at my own little naked body and feeling confused and tired and seeing a nurse notice me, look a little panicked, come over, and I was out again. Surgical memories are an integral part of my self-understanding. 

My second surgery happened when I was sixteen. I had acute abdominal pain and was rushed to the emergency room. After identifying a water bottle-sized cyst pushing up against my stomach and intestines, I was sent into surgery to remove it (as well as the ovarian cyst it was pushing on, the actual source of acute pain). I went into surgery being told I might have to have my ovaries and uterus removed if anything appeared malignant. The cysts all ended up being benign, though there was no conclusive idea about why I’d grown a large, free-floating cyst (most cysts and tumors grow on organs or tissues). One theory included that I had absorbed a twin in utero during early stages of development, which matched other complications that surrounded my pregnancy and birth.

Ten years later, the cyst regrew (which I had been warned was a possibility). This time, I didn’t have health insurance and had to wait three months on bed rest before I could be scheduled for surgery at San Francisco General Hospital, and was then in bed and out of work for an additional month while recovering from invasive abdominal surgery. A new theory the doctors developed was that I had Turner’s Syndrome, an intersex condition that sometimes results in unusual cyst or tumor growth. After going through genetic testing, the results were inconclusive. If I did have Turner’s, it was “mosaic Turner’s,” where some tissues/cells have the chromosomal differences but others didn’t. I never followed up on this because it didn’t matter much to me.

About six months after this second abdominal surgery, I was hit by a car while riding my bicycle to work in San Francisco. It was a hit-and-run (the dude yelled “sorry” out the window before speeding away). My arm was snapped in half like a twig, as it had absorbed the entirety of the impact of the car. All things considered, I was pretty lucky. No head damage, no hip or spinal damage. Again, I had no health insurance so had to wait nine days for surgery. San Francisco General sent me home with a splint (no sling) and a bottle full of oxycodone. A week later, after surgery, when the general anesthesia wore off, I was in the worst pain of my life. What most folks don’t know is that after you wake up from surgery, you don’t really feel much pain at all because the general anesthesia is numbing your body. This wears off after about 18-24 hours, when the full force of what just happened to your body finally hits you. It’s scary, jarring, and disorienting. No one told me I would be in so much pain. I came to find out that I had spent 7-8 hours face down on an operating table with my left arm wrenched around so that the backside of my arm was exposed for the surgeon to insert a plate and twelve screws. Would have been nice to know beforehand, but instead, I wound up crying from pain and fear for about an hour before I was able to get an answer as to why my shoulder was in so much pain when it was my arm that had been operated on.

In hospitals, you often forget that your body is yours. We live in a culture where so many people, for so many reasons, don’t experience their bodies as “theirs.” Some people dissociate because of abuse or trauma. Some people grow up in communities where your bodies will be laboring bodies and ignoring pain or discomfort is part of how we make a living. Others have been taught to care only for their minds and that their bodies are inconsequential, and so they’ve learned to separate body from mind, disconnecting things that are intimately interwoven. And others have experienced many other kinds of dysphoria, including around gender.

My fifth, and most recent, surgery was almost three years ago, when I had flesh and glands removed from my chest to give it a narrowly-defined “male contour” by a private, plastic surgeon in Marin. Of all my surgeries, this was the one that I had the most mixed feelings about because 1) it was expensive and I was paying out-of-pocket, 2) it was the only surgery that wasn’t physically life-saving, and 3) it was the only surgery I’ve had that people have congratulated me for. While some people may have their choice of surgeon covered by insurance, mine wasn’t. There may also be some trans people who say that “gender affirmation” surgeries are life-saving. I don’t know how to explain what this surgery was to me. It felt like a way to manipulate my body so it could move with more ease through its day. I didn’t want to think about whether or not I wanted to bind my chest, which was a very painful practice that exacerbated my asthmatic symptoms, gave me rib and intercostal pain, and resulted in rashes from the tight and uncomfortable fabric pressing up on my skin all day. I also had to be strategic about what kinds of fabrics to wear so that the strange shape the binder left my body in would go undetected. It also made going to the gym, changing, wearing tank tops, going to the beach, and other activities like exercising outdoors or hiking somewhat uncomfortable, if not unbearable in other moments.

I never experienced the kind of dysphoria that many other trans people describe. I knew that it was the world that had led me to feel uncomfortable with my body, rather than some fundamental disconnect between my body and my mind. Because I don’t experience or believe that minds and bodies are separate entities, I know that those thoughts and experiences were put into me through the aggressive messaging we all receive through TV, movies, magazines, billboards, and other media about what male and female bodies are supposed to look like, and this has been very narrowly defined.

With my four other major surgeries, people didn’t really ask me a lot of questions. People almost seemed afraid to ask. People weren’t offering to help me with recovery. People seemed scared and silent around it. When it came to my chest surgery, there were “congratulations!” and offers to help, and lots of questions and curiosity. I wish I’d received “congratulations!” for surviving life-saving surgeries that were much more invasive. I didn’t want to receive congratulations for my chest surgery. I wanted people to be angry that I had been made to feel so uncomfortable with a part of my body that I was going to decide to have it removed. A part of me has died before the rest of me. That’s something I sit with and think about quite a lot. I had a grieving process that I went through, and I’m content with my decision to alter my body in irreversible ways. It has opened up a certain ease that I haven’t had since I was much younger.

The most bodily dysphoria I have ever experienced was in the week between my bike-car accident and the surgery. Because my left arm was not connected to the rest of my body by bone (it was dangling by muscle, ligaments, nerves, and other tissues), I couldn’t control it. I had nightmares that would end with me throwing my arms up to protect my face or catching myself from falling. When I’d jerk my arms up, the pain would wake me up from the nightmare. A couple of times, when I was awake, I had an itch and my left shoulder jerked to move my left arm to scratch it, but because the rest of my arm wasn’t connected by bone, it didn’t move. In my mind, my motor cortex was telling me I’d done the appropriate action to move my arm, but my visual cortex was telling me my arm hadn’t moved. The room began to spin and I nearly passed out and vomited before I was able to reach over with my right arm and “find” my left arm. As soon as I touched my left arm with my right hand, the spinning and nausea stopped immediately and my body-mind was back in alignment. I’ve never experienced anything nearly so disorienting from gender-related dissonance. When people talk about dysphoria of any kind, this is the experience I draw upon to connect.

Why have I shared all this? Perhaps to speak from a unique experience of having been operated on five times before the age of thirty, and under very different circumstances. Most trans people might only have gender-related surgeries, and so might have no basis of comparison to other kinds of surgical procedures and the ways they are experienced, both by the person being operated on and by those around them. My hope would be that sharing these experiences could give people some insights into the ways we value trans-surgeries and other kinds of surgeries. And that for some people, trans-surgeries may not be “life-saving” in the same ways that other kinds are. I fully recognize that people’s psychological health may be intimately connected to their ability to change their bodies to make them feel more like “home,” and in some ways, not having access to support (including healthcare and surgeries) could lead to life-ending consequences, like suicide or other harmful behaviors.

We also think of surgeries as quick, easy fixes. In my experience and the experiences of those I’ve known, the surgery and immediate recovery period is just a small part of that experience. I still have numbness and shooting pains in my arm, abdomen, and chest, from all those surgeries. Sometimes a body can have the look of full function, but not actually be able to do all the things it could before. For example, my arm looks relatively “normal,” despite the 14-inch scar running up the back – but I have nerve damage, not from the accident, but from the surgery.  I can’t do push-ups or other movements that compress my left elbow, and my left hand always feels like I just pulled it out of a bucket of ice water, complicating my relationship to my body as a (former?) musician. My abdomen looks relatively normal, but I can’t twist myself in particular ways. I can’t lean my chest against things because the combination of surface numbness and the experience of pressure result in this weird kind of pain. I don’t like parts of my chest touched because the nerve endings send odd, shooting sensations that don’t match my mind’s idea of where it’s being touched and this is really disorienting.

I don’t share this to make people feel badly. I share it because culturally, in the Euro-American West, we think that bodies can be intervened upon, “fixed,” made to look “normal” to us and to others, but that cutting open a body and adding prosthetics or removing parts, will fundamentally change it, forever. Sometimes those changes are necessary and can allow for new possibilities, and sometimes, in addition to those positive changes, we have to learn to adapt to other foreclosures, or unexpected losses of capacity, movement, sensation, or connectedness. Supporting someone who is having surgery means different things for different people, but it should always involve challenging the assumption that once someone is back to school or work (or whatever they may do with their time), that all the healing is done. Recovering from surgery is also a long-term psychological process, and sometimes one that you go through for the rest of your life.

Trans Moral Panic: Let My People Go (Pee)

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Every movement has its moments of backlash. The current reactions to the increased visibility of transgender and gender non-conforming people include presidential campaign platforms that advise against allowing transgender women to use women’s public restrooms legally and safely in some states. These stances also make it potentially illegal and dangerous for an entire spectrum of people read as gender non-conforming to use public restrooms. While laws regulating the mandatory consonance of sex-on-birth-certificate and perceived gender will endanger anyone who becomes the target of gendered suspicion while using restroom facilities, transgender women (described by opponents of gender diversity as “men dressed as women”) are the focus of the current right-wing outcry.

Before writing any further, I do need to take a moment to situate the perspectives and analyses that will follow. I will be making reference to issues of sexual violence. As someone who has committed their life’s work to intervening on gendered violence – of which I believe sexual violence is a part – I offer these reflections in contribution to ongoing public discourse that will hopefully bring us to different moment of agency in better unravelling the ideas, beliefs, laws, relations, and institutions that have locked pervasive forms of gendered and sexual violence in place.

For years, I have discussed issues of sexual agency and sexual violence with middle school and high school students on a weekly basis, and their struggles and triumphs additionally inform my thoughts. I have spent time with dear friends, respected colleagues, and former partners who have survived physically, spiritually, and psychically, with strength, with struggle, with rage, with pain, with shame, with persistence, with silence, with the weight of worlds and histories. All I can say is that I hope my words do not re-injure, and that if they do cause any discomfort, I will do my best to live up to the responsibility of inciting this difficulty. I tread steadily yet cautiously through mine-filled terrain in the interest of demanding more space for collective healing and accountability.

My hopes in today’s writing are twofold: 1) to demonstrate the increasing interconnection of two storied figures: the ‘heterosexual male pedophile’ and the ‘homosexual cross-dressing pervert’* and 2) to illuminate the ways that discussing our national anxieties around pervasive sexual violence are co-opted through the fear-baiting, transphobic rhetoric of right-wing politicians and organizations.

To elaborate on the increasing proximity of the two images of the ‘heterosexual male pedophile’ and the ‘homosexual cross-dressing pervert’ (both images having their own history and production), I want to point to the ambiguity of this hybrid figure, whose reality is thought to materialize in the personhood of a transgender woman, within the current public debates regarding restroom access. This new, combined image is that of a bisexual/queer ‘monster’ of gender and sexuality, able to absorb any and all cultural anxieties and fears of sexual predation, simultaneously dangerous to women, men, boys, and girls, adults and children alike. The right-wing agenda of sexism, homophobia, and transphobia would have us hear this narrative uncritically, to the detriment of building alliances across genders and developing accurate representations of transgender people.

This hybrid, fictional figure – who, I must reiterate, is often confused with actual persons who live as transgender women or other gender non-conforming people – is the ultimate scapegoat of the moment, especially in this presidential election season that is so very much about gender, in so many ways, regardless of whether or not we name those undercurrents explicitly. I am afraid of how difficult this storied image might be to undo in the long-run, and I hope that naming the harm of this fictional figure and teasing apart its component parts might help us to more actively and forcefully intervene on it and name it as the lie and slander that it is, criminalizing and demonizing entire genders in one fell swoop.

Furthermore, current political rhetoric is making strategic use of pervasive anxieties and fears of sexual violence. This “weaponizes” sexual discourse in order to instill (sometimes, or often, understandable) fears and anxieties in a public collective psyche, in which many members are survivors of sexual violence or know people who have been immensely impacted by sexual violence. Politicians, like Ted Cruz, use the threat of future sexual assault to galvanize discrimination against scapegoated transgender women. The creation and manipulation of the conflated images of the pedophile and the cross-dresser (which have appeared together before in the image of the gay male who may both cross-dress and seduce young boys and men – a figure of moral panic that predominated in a past era) are specifically used to harness collective emotional states of pain, anxiety, fear, distress, and trauma around sexual violence for political and financial gain.

All politicians making use of this new moral panic of trans women in restrooms are harming people through this “weaponization” of sex, a term used in Joseph J. Fischel’s recently released Sex and Harm in the Age of Consent. I am arguing that when sex is “weaponized,” or put to violent uses, the speaker is performing an act of sexual violence. Politicians, including presidential candidate Ted Cruz, is performing an act of collective sexual violence through speech. I say this understanding that what I am outlining here cannot be compared with individual experiences of sexual violence that are physical in nature. I would not be so careless as to draw comparisons of this kind, nor to describe these actions as sexual violence in order to lessen the gravity with which we approach the work of working to mitigate sexual harm as it occurs in person, physically.

When looked at this way, we can see just how normalized this form of sexualized rhetorical torture is, en masse. Because of the manner in which this debate came to articulate itself, many working for gender justice struggle to engage in productive discussions across diverse communities of survivors and non-survivors. This occurs because the originating framework and terms of debate incite painful and understandable reactivity. Pain, upset, and anger must have space, and we will continue to work for moments when we can engage in the forms of collective healing that include thoughtful, calm reflection and discussion as well.

As an educator with youth on issues of gendered and sexual violence, these analyses are seen and felt on a weekly basis as I struggle to discuss issues of sexual agency and autonomy, consent and coercion, communication, interpersonal and institutional violence, sexism, racism, homophobia, transphobia, and so much more with my students. I want to provide them with useful tools and I know that as hard as I try to stitch together some narrative that might sound cohesive, that might make sense, I know I’m also speaking against and alongside all these other overt and covert messages that shape young people’s expectations and tolerance of sexual violence. Back to work it is…

*Special thanks to C.S. for providing me with thoughts and reflections on these important issues. This blog would not have been possible without your valuable insights on gender, sexuality, identity, and violence.