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What are the facts and figures behind the trans issues? What evidence exists? What evidence is still missing? How many people experience gender dysphoria, or as it is now known, gender incongruence (GI)?
Gender incongruence (GI) is the state where a person feels their assigned gender at birth is not the same as their internal and lived experience. The more commonly used and problematic term is transexual.
GI has an unknown origin. Many factors, alone or together, could be involved: psychological, genetic, epigenetic, hormonal, brain development, and environmental. We don’t know which factors apply in which circumstances or how, or if they interact.
Some of the many reasons that there are no reliable figures for the number of GI people in the population (the estimates range from 0.1% to 0.5%) are:
- Many GI people keep secret their desire to be of the opposite sex to avoid hatred and prejudice.
- We don’t know how many explore the idea of being the opposite sex and then choose to live as they are.
- We don’t know how many live as both genders at different times (for instance, living as one gender during the week and as the opposite gender at weekends).
- Official documents in most societies do not give people the option to state that they are trans or GI.
GI or trans people are not to be confused with those who are androgynous or of indeterminate gender or those with a genetic condition with gender identity implications. Again, there are no reliable figures, and the range of people born with indeterminate gender or intersex traits varies hugely from 0.3% to 1.7%.
Neither are trans people to be confused with those who identify as gay or asexual. Around 2% of the population are asexual, meaning they do not have a sexual attraction of any kind. Asexuals are between four and 20 times more numerous than GI people and are faced with their own challenges, which seem to be absent from public awareness.
Figures for the numbers of gay and lesbian people vary from around 3% to 5%. Various researchers have found that between 15% to 30% of people admit to having had a same-sex attraction or experiences but do not self-identify as gay or bisexual.
There are slightly more people who identify as bisexual than lesbian and gay put together. The majority of young people (around 60%) admit to having had at least one same-sex experience. The reality is that most people are not 100% heterosexual.
If the same variation that applies to sexuality applies to gender identity, that would indicate that most people have thought about being a gender other than that assigned at birth, at least fleetingly.
From our own experience of life, we know that there is a huge variation in all the possible dimensions of human outward gender appearance. We all know feminine women, typical women, masculine women, feminine men, typical men and masculine men. In some academic literature, other terms have been used to describe the diversity of gender perception and identity: binary, non-binary, third gender, fourth gender, and even fifth gender.
They can feel very differently inside wherever someone sits, outwardly, on the femininity-masculinity continuum. A person who looks like a feminine woman on the outside can feel very masculine on the inside. A very masculine man can sit anywhere on the heterosexual, bi-sexual or homosexual continuum. Intersex people have the same range of sexuality and gender identities as the rest of the population.
It seems that any permutations can and do exist. When we add time to the picture, it seems that each of us moves in various ways on each of the continua. For example, as we get older, we all become more androgynous. For some, that leads to a loss of libido. Some men who were masculine and actively heterosexual in their youth become feminine or either passively homosexual or transexual (those who wish to change gender) in middle age.
Indeed, that coincides with some of the scant research data. Middle-aged men and young girls make up a disproportionately large number of GI people. Young girls who see the social preference which is given to boys start wishing they were boys. Over time, such wishes seem to progress to GI in some cases.
It seems that GI, for most, is transient, and for others, it is enduring. For some, it is triggered by internal changes, and for others, by cultural factors.
Throughout history, most societies have accounts of people we would now describe as transgender or GI. Some indigenous North American tribes revered what are now called ‘two-spirit’ people, while other tribes ostracised them.
That range of approaches seems to be a microcosm of the pattern around the world throughout time. In many countries, even today, a person who lives or behaves outside their socially-expected binary gender role commits a punishable ‘offence.’ By contrast, the ‘kathoey’ more commonly known as ‘ladyboys’ are famous in Thailand and worldwide. Many are celebrities, and some are politicians.
As with so many variations in human life, culture plays a large part in whether and how diversity is expressed. Culture even seems powerful enough to shape self-perception. In India, many Hijra do not consider themselves male or female, or even transgender, but the ‘third gender’.
In many countries where there is cultural pressure to be male or female, that pressure causes the same self-perceptions to be expressed differently. For example: “I am trapped in the wrong body.” Perhaps the same people, if they had been enculturated in India, would live as the third gender and in Thailand as ladyboys.
A chain of question follows from such observations. In cultures where any of the various forms of the third gender are legally recognised or accepted, is there a greater number of people who live in various ways other than the male or female convention? Yes.
By contrast, many Hijra die after knowingly having taken the risk of seeking ‘backstreet interventions’ because they cannot afford to pay for qualified surgical help. Perhaps that indicates how driven some GI people are; how real the feeling is for them.
Even where transgender people are legally recognised, as in India, they are still subject to prejudice and stigmatisation. At best, the more mainstream population has an uneasy, ambivalent relationship with such diversity. In India, many Hijra are ostracised.
In Thailand, many Buddhists believe that if someone has sinned in a previous life, they are reincarnated as kathoey and, as such, are treated as though their alternative lifestyle was not their choice. It seems that how a culture treats and perceives GI people plays a large part in their well-being.
In cultures where natural human diversity is not welcomed, perhaps only those people who feel very strongly that they are of a gender other than that assigned at birth would wish to face a lifetime of societal prejudice, hatred, fear and ignorance.
Compared to the general population, people who have received a diagnosis of gender incongruence (GI) are:
- Six times more likely to have a mood or anxiety disorder
- Six times more likely to attempt suicide
- Three times more likely to be on medication for depression and anxiety
It is little wonder the mental health of so many GI people is so poor; they are societally deprived of the three things that people need most:
- Safety and security
- To be heard and understood
- Love and acceptance
Given what we know lies ahead for many GI people, it is reasonable to ask: should society do whatever it can to help? In my view, that is a big, yes.
Would widespread acceptance help? Yes, the fewer negative experiences GI people have, the less likely they are to have suicidal ideation. Changing cultures at the societal level is a multi-lifetime project. In the meantime, many people want and need help now.
Changing the law to recognise GI people, giving them the rights all other people take for granted, and protecting them from prejudice and discrimination would help. Again, that exists in some parts of the world. Even in such places, culture generally overpowers law unless and until there is understanding and rigorous enforcement.
Most immediately, society can help with therapy. That takes society into an area filled with scientific, ethical, moral, legal and practical challenges and uncertainty. Despite the difficulties, all right-thinking citizens want to help GI people live the best lives they can.
What do we need to know to enable us to help? It would be useful to know what causes GI.
Some trans people think it is no more valid to ask what causes heterosexuality than to ask what causes GI. What causes people to be heterosexual, homosexual, bisexual, asexual, or GI is unknown. There are vast numbers of theories, and none of them seems to account for the facts.
Sometimes, in science, having no verifiable explanation for a phenomenon indicates multiple causes of the same outcome. Perhaps it is best to stop looking for a single explanation and determine which causes seem to apply to which people in which circumstances.
The range of variations in sexual orientations is the same with GI people as they are with the rest of the population. However, about 70% of young GI people eventually settle as same-sex attracted without engaging in any hormonal or surgical treatment.
That poses a chain of questions. Is it possible that some people who find themselves attracted to the same sex experience cognitive dissonance that makes them conclude: ‘Therefore, I must be of the opposite gender to my appearance?’
Could it be that the cognitive dissonance becomes embedded; through repetition, it turns into a settled belief and eventually into their identity?
That is just one theory of how GI develops. Before taking steps as drastic and irreversible as hormonal and surgical intervention, does it not seem reasonable that all treatable psychological causes are ruled out first?
Worldwide, the principal rules of health care seem to be:
- First, do no harm
- Take no unnecessary risks
- Be sure any proposed intervention has been proven necessary, effective and safe
In all healthcare, risks have to be balanced. If the risk to life of not having hormonal or surgical intervention is verifiably greater than the risk to the life of having such intervention, then it is justified.
If those principles were being followed to protect all GI people, it would be reasonable to expect to see:
- An assessment of the risk to life
- Evidence that all psychological causes of their GI had been explored and evidentially ruled out
- Every possible psychological treatment had been tried
- An evidence-based approach to each individual treatment plan
- A huge body of research data supporting and guiding each type of possible intervention
- A detailed and thorough education programme shows GI people how to deal with their GI without resorting to hormonal or surgical intervention risks
- Verification that all viable alternatives had been tried and failed
What kind of research data would be useful to enable society to decide how to best help GI people?
It would be useful to know the number of people affected and their physical and mental health before, during and after each stage in the following apparent hierarchy of GI intensity. Those who have:
- Fleeting thoughts of GI and took it no further.
- Experimented with being the other gender in private but took/take it no further.
- Experimented with being the other gender in public but took/take it no further.
- Chose/choose to live at least part of each week as the other gender in public but took/take it no further.
- Chose/choose to live full time as the other gender in public but took/take it no further.
- Chose/choose to live as above and take hormones, but took/take it no further.
- Chose/choose to live as above and carry out partial reassignment surgery, but took/take it no further.
- Chose/choose to live as above and carry out complete reassignment surgery.
It would also be useful to know how many people change their minds and withdraw from any category above, where possible or regret their choice, or become suicidal where withdrawal or reversal is not possible after treatment.
There is, alas, a dearth of such information and what little exists is less than reliable. If we had such information, we could take an evidence-based approach to treatment and support of GI people.
In the absence of such knowledge, however well-intentioned the rest of society may be, it is at risk doing irreversible damage to a group of people who are already vulnerable.
For instance, if it emerges that the vast majority of people with GI ideation, left to their own devices, do not move through the categories above, is any society that adopts an ‘affirmative only’ policy at risk of inadvertently engaging in conversion therapy?
To elaborate, could ‘affirmative only’ policies reinforce GI ideation to the extent that a person feels deprived if they cannot transition to the opposite gender?
Does ‘affirmative only’ actually reinforce and encourage GI thoughts, feelings and behaviour?
Does cognitive dissonance kick in and intensify the GI disposition? For example: ‘All the experts are telling me I am in the wrong body; I must be. I should transition’.
Does the ‘affirmative only’ approach amount to conversion therapy? For example, by converting people into full transexuals who would have lived happily as gay/lesbian after exploring their gender?
The answer to those questions is that we don’t know: there is insufficient evidence to make any evidence-based decisions.
Perhaps there are explanations for the absence of evidence and an apparent unwillingness of professionals to seek the evidence. Could it be that after the ‘affirmative only’ approach was adopted and became orthodoxy, it killed off and suppressed the desire to obtain the necessary evidence?
Are we witnessing GI treatment based on ideology rather than evidence if that is the case?
Professor Nigel MacLennan runs the performance coaching practice PsyPerform.