Medical professionals increasingly agree: Trans women are female, trans men are male

“Trans women are male” is one of the most well-worn attacks leveled against trans women – a straightforward assertion that gender-variant identity itself is not possible, and by extension neither are we. It is delivered with the self-assured smugness that this truth is so obvious as to need no explanation, grounded as it is in the particulars of sexed anatomy, X and Y chromosomes, or some simplified folk notion of “biology”.

Words, labels, and concepts

Taken straightforwardly and purely in terms of content, such statements are tautologies that prove nothing. What they do illustrate is that this is not a disagreement about physical facts or the state of the world in reality. This is a dispute over the application of labels like “male” and “female”, and in this case, the recognition of trans people’s genders as valid. For example: If “male” is construed to mean “has a prostate” and “female” is construed to mean “has a uterus”, the statement “Trans women are male” simply communicates the fact “Trans women have prostates” or “Trans women don’t have uteruses”. Those facts are not disputed by anyone, so the statement is simply redundant.

So why the insistence on angrily and forcibly applying these misgendering labels to trans women and men, despite our strenuous objections? It’s because definitions such as these can be constructed in a way that’s designed to question and reject the authenticity of trans women’s genders. The intentional conflation of multiple definitions of “female” and “male” is meant to invoke the connotation that trans women are mostly like the other 99.4% of individuals placed in the “male” bin: cis men. And if a trans woman can be regarded as essentially like a cis man, our genders can then be much more easily invalidated in everyday life – after all, why let a cis man use women’s restrooms, dressing rooms, and showers?

The factual and undisputed statement that trans women have prostates is far different from the normative and contestable claim that trans women should generally be regarded as essentially like cis men since both have been (intentionally, deliberately) placed in the category “male”. Pointless assertions of obvious anatomical facts – “trans women don’t have uteruses” – serve as a shield to excuse ongoing cultivation of raw transphobia: pervasive, everyday misgendering and cries of “No men in women’s bathrooms!” That transphobia is enabled by the choice to place together two very dissimilar groups on the putative basis of shared characteristics that are wholly irrelevant in most circumstances in life, such as the possession of a prostate or XY chromosomes. Such definitions are perhaps relevant to cancer screening or colorblindness – but not whether a trans woman should be publicly recognized as a woman or allowed to use women’s facilities. And not a single trans person is fooled by this transparent bait-and-switch.

The application of the labels “female” and “male” to trans people is a matter of flexible personal choice, not a matter of indisputable physical facts like having a prostate. No inherent meanings of the terms “male” or “female” are built into the structure of the universe; it cannot be said that it is somehow factually incorrect to call trans women female. A choice of definition may be more or less useful for a given purpose – in the context of general social interactions, “female” can be used to refer to individuals who can broadly be regarded as women in everyday life; in the context of healthcare, “male” can be used to refer to those who will require prostate cancer screenings; for no reason and not very usefully at all, “male” could even simply mean “people with red hair” – but it is still ultimately arbitrary.

If one can make the choice to call trans women “male”, one could also choose to call trans women “female”. And trans people aren’t the only ones who’ve made the latter choice. Contrary to loud and ignorant assertions that trans people are “denying reality” or “ignoring biology”, usage of “female” and “male” in ways that respect and reflect trans people’s genders has become surprisingly common even among major professional medical groups in fields such as endocrinology and gynecology, as well as hospitals and various researchers.

These medical professionals and researchers use gender-affirming terminology

The Endocrine Society recently released its updated clinical guidelines for the care of transgender patients and recommendations regarding hormone therapy (Hembree et al., 2017). These guidelines were cosponsored by the American Association of Clinical Endocrinologists, American Society of Andrology, European Society for Pediatric Endocrinology, European Society of Endocrinology, Pediatric Endocrine Society, and the World Professional Association for Transgender Health. Throughout the document, the authors consistently refer to trans women as “transgender females” and trans men as “transgender males”, and explicitly define trans women as “transgender female”:

Transgender woman (also: trans woman, male-to female, transgender female): This refers to individuals assigned male at birth but who identify and live as women.

Clinicians should monitor both transgender males (female to male) and transgender females (male to female) for reproductive organ cancer risk when surgical removal is incomplete.

We suggest periodically monitoring prolactin levels in transgender females treated with estrogens.

We suggest that transgender females with no known increased risk of breast cancer follow breast-screening guidelines recommended for non-transgender females.

Notably, the publication refers to trans women as female in the context of healthcare recommendations, undermining the common but misinformed argument that misgendering labeling of trans people is necessary for appropriate care. The authors even affirm that one can indeed be female and have a prostate:

We suggest that transgender females treated with estrogens follow individualized screening according to personal risk for prostatic disease and prostate cancer.

Additionally, the Endocrine Society has asserted that there is “a durable biological underpinning to gender identity” – in other words, gender identity, such as a trans woman’s identity as female, can itself be considered an aspect of biological sex.

The American College of Obstetricians and Gynecologists, in a January 2017 committee opinion recognizing the importance of gender-affirming treatment for transgender adolescents, repeatedly refers to trans girls as “transgender females” and trans boys as “transgender males”:

The World Professional Association for Transgender Health estimated prevalence at approximately 1 in 11,900 transgender female (male-to-female) youth and 1 in 30,400 transgender male (female-to-male) youth (4).

At age 16 years, cross-gender puberty induction can begin. For transgender males, this comes in the form of testosterone therapy; for transgender females, it involves the use of estrogen and androgen blockers such as spironolactone.

Lurie Children’s Hospital refers to treatment with HRT as “estrogen for transgender females” and “testosterone for transgender males”.

St. Louis Children’s Hospital also refers to trans girls as “transgender females” and trans boys as “transgender males”:

Administering pubertal blockers, which delay puberty and suppress unwanted and irreversible secondary sexual characteristics; for example, deepening of the voice and facial hair for transgender females and breast development for transgender males.

Fenway Health of Boston, in their 2015 document “The Medical Care of Transgender Persons”, repeatedly calls trans women “transgender females” and trans men “transgender males”.

A number of published papers on medical treatment for trans people also refer to trans women as “transgender females”, including a recent publication on vaginoplasty (Milrod & Karasic, 2017), another on sperm cryopreservation (Nahata, Tishelman, Caltabellotta, & Quinn, 2017), and another on care for trans adolescents (Olson, Forbes, & Belzer, 2011). Numerous articles using similar terminology can be found with minimal effort.

Referring to trans women as female and trans men as male is entirely acceptable

These choices of terminology by medical professionals give lie to the notion that calling trans women female is in any way “scientifically” incorrect. Scientific research and medical treatment are by necessity as tightly coupled to reality as possible – these areas permit little room for error, and it would be quite obvious if the mere use of these gender-affirming terms were somehow upending or ignoring reality. It is not.

Trans women are female – with female penises, female prostates, female sperm, and female XY chromosomes. Misgendering us for “scientific” reasons is not some necessary component of recognizing and working within reality; this is merely an excuse for trying to deny and overturn our genders in any possible context that could conceivably permit it. That excuse is now shown to be flimsy and irrelevant. So, am I to listen to an egg on Twitter ranting at me about his passing familiarity with middle school biology, or to the endocrinologists and gynecologists I entrust with my health? ■

Has your understanding of “male” and “female” changed or become more nuanced over time? Tell us about it in the comments!

References

• Hembree, W. C., Cohen-Kettenis, P. T., Gooren, L., Hannema, S. E., Meyer, W. J., Murad, M. H., . . . T’Sjoen, G. G. (2017). Endocrine treatment of gender-dysphoric/gender-incongruent persons: an Endocrine Society clinical practice guideline. Journal of Clinical Endocrinology & Metabolism, 102(11), 1–35. [Abstract]
• Milrod, C., & Karasic, D. H. (2017). Age is just a number: WPATH-affiliated surgeons’ experiences and attitudes toward vaginoplasty in transgender females under 18 years of age in the United States. Journal of Sexual Medicine, 14(4), 624–634. [Abstract]
• Nahata, L., Tishelman, A. C., Caltabellotta, N. M., & Quinn, G. P. (2017). Low fertility preservation utilization among transgender youth. Journal of Adolescent Health, 61(1), 40–44. [Abstract] [Full text]
• Olson, J., Forbes, C., & Belzer, M. (2011). Management of the transgender adolescent. Archives of Pediatrics & Adolescent Medicine, 165(2), 171–176. [Abstract] [Full text]