“Why can’t you just be gay?” Why I, a trans lesbian, can’t just be a gay man

Zinnia JonesOn an astonishingly frequent basis, trans people who come out are met with a peculiar reaction. Those who come out as trans women may be asked, even by well-meaning individuals, “Why can’t you just be a gay man?” And trans men, too, face the flip side of this: “Can’t you just be a lesbian?”

This misconception rather obviously stems from a failure to separate gender identity from sexual orientation: Trans women are not some extreme form of hyperfeminine gay men, nor are they necessarily attracted to men at all; trans men are not an extreme form of butch lesbians, and may not even be attracted to women. Continue reading

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Additional information on transition treatment for trans women with BRCA1 or BRCA2 mutations

Zinnia JonesI’ve previously covered existing research on hormone therapy for trans women who are at an increased risk of breast cancer due to BRCA1 or BRCA2 mutations. As transitioning with estrogen induces the growth of breast tissue just as in cis women, breast cancer can be a significant concern for this population. A recent case report elaborates on the treatment options and approaches for trans women with BRCA1 or BRCA2 mutations who have transitioned or are seeking transition.

Zhirui et al. (2018) describes the case of a 37-year-old trans women who is BRCA2-positive, has already undergone genital surgery, and has since been taking daily estradiol for several years. Notably, as male-assigned people with BRCA mutations are at an increased risk of prostate cancer and reassignment surgery does not remove the prostate, regular screening for prostate cancer was recommended:

Given the fact that she had undergone transgender surgery including bilateral orchiectomy with ongoing hormonal supplementation, her cancer risks were difficult to estimate. However, she was counseled regarding the risks of breast and prostate cancer. Chemoprevention with anti‐estrogen agents for breast cancer was also discussed, but she was not a good candidate given her ongoing estrogen supplementation. Subsequent referrals were made to general surgery and urology to further discuss her breast and prostate cancer risks, respectively. …

Screening for prostate cancer is recommended for men who are carriers of BRCA mutation. The serum PSA levels that trigger a diagnostic prostate biopsy in this patient population are currently set at 3 ng/mL. We do believe, however, that in the case of a transgender BRCA mutation carrier who is already castrated and has undetectable levels of PSA, any change in DRE or detectable PSA levels should trigger a diagnostic prostate biopsy.

In this case, the patient chose to undergo prophylactic mastectomy and reconstruction:

Her breast cancer risk, however, is increased due to her requirement for hormonal replacement. She decided to proceed with bilateral prophylactic nipple sparing mastectomies with immediate reconstruction using deep inferior epigastric artery perforator (DIEP) flap in 2016. Pathology revealed no evidence of malignancy.

An earlier publication (Corman et al., 2016) reports on the case of a trans woman with a BRCA2 mutation who developed breast cancer after 7 years of hormone therapy, with recurrence 30 months after right mastectomy. The authors offered the following treatment and screening recommendations for trans women with BRCA mutations:

A BRCA2 mutation complicates management and follow-up in MtF TG persons. In those who have a BRCA2 mutation diagnosed before initiation of hormonal therapy, cancer risks and alternatives to hormonal therapy (e.g., prosthetic breast augmentation) should be discussed. Male BRCA2 mutation carriers should undergo surveillance that includes regular self and clinical breast examination, but in men, imaging studies and prophylactic mastectomy are not part of guideline recommendations (National Comprehensive Cancer Network 2016). In BRCA2-positive MtF cases that have hormone-induced breast formation, it would seem prudent to adopt yearly screening mammography and/ or MRI, as would be the case in adult genetic females (Balmaña et al. 2011, National Comprehensive Cancer Network 2016). BRCA2-positive patients have higher risks for prostate cancer. As complications of prostatectomy can be significant, removal of the prostate is generally not part of the sex reassignment surgery of MtF patients (Hembree et al. 2009). Prostate examinations should be performed at least once a year along with prostatespecific antigen measurement. During follow-up, the risk of other potential BRCA2-associated cancers should be kept in mind.

Overall, trans women on hormone therapy are not at any greater risk of breast cancer than cis women (Joint et al., 2018). However, for those with an elevated risk of cancer due to these mutations, regular screening and surveillance is essential.

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Transgender surgical reversal statistics: A clearer picture emerges

Zinnia JonesOctober 2017 saw a spate of fearmongering articles alleging a rise in demand for surgical reversal of transgender genital surgeries. The Independent claimed that such reversal surgeries are “more in-demand than ever before”. What does this new demand look like?

It’s potentially why some of those seeking “reversal” surgeries are heading to a clinic in Serbia, where Professor Misoslav Djordjevic has been performing them for five years at the Belgrade Center for Genital Reconstructive Surgery.

A specialist in genital reconstruction with 20 years of experience, Prof Djordjevic began conducting the innovative procedures after a transgender patient who had undergone surgery to remove male genitalia requested a reversal.

It’s by no means a common practice. He has performed just 14 surgeries to date and is currently in the process of treating two “reversal” patients, reports The Daily Telegraph, explaining that the procedure is extremely complex and can cost up to €18,000 (£15,965).

Presenting data in this way is unhelpful. 16 postoperative trans people have sought surgical reversal – but out of how many? A naked numerator like this obscures understanding, and encourages imaginative speculation that may not align with reality. Is it 16 out of 100 total trans people who’ve had genital surgery? This would be very concerning indeed – a 16% rate of surgical reversal. Is it 16 out of 10,000? This would be a rate of 0.16% – not exactly an epidemic. The problem is that most people aren’t aware that there are millions of trans people in the world: 0.6% of the population being trans means about 44.6 million people around the world are trans.

Fortunately, more useful statistics are now available on the practice of surgical reversal of trans genital surgeries. This month, WBUR CommonHealth reported on findings from a still-unpublished study:

The most recent data on transgender patients who change their mind after surgery is a study led by Oregon Health and Science University, which has not been published but was presented at a conference earlier this month. In it, 46 surgeons from around the world reported reversing 36 transgender surgeries, including 16 phalloplasties, after treating somewhere between 18,000 and 27,000 patients.

36 surgical reversals out of 18,000-27,000 trans patients who’ve received surgery is a reversal rate of 0.13-0.2%. This is consistent with existing studies finding that rates of regret following genital surgery of about 2%, and indicates that only a small fraction of those who do experience regret will go on to seek reversal surgery. I’ve been in touch with the study’s authors, and while the study itself is not yet available, I look forward to continuing to cover this non-epidemic – denominator and all.

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“Rapid onset gender dysphoria” study: An impossibly wide net of alternative etiologies

Zinnia JonesOne of the most striking features of the recently published “rapid onset gender dysphoria” study is just how many claims are made regarding possible alternative causes for the mere appearance of gender dysphoria rather than genuine gender dysphoria, and how little evidence is presented to substantiate the notion that any of these potential causes would lead to the development of either apparent or genuine gender dysphoria. The study author, Lisa Littman, emphasizes the importance of these supposed causes at length, alleging that other factors could lead these youth to believe falsely that they have gender dysphoria:

Parents described that clinicians failed to explore their child’s mental health, trauma, or any alternative causes for the child’s gender dysphoria. This failure to explore mental health and trauma occurred even when patients had a history of mental health disorder or trauma, were currently being treated for a mental health disorder, or were currently experiencing symptoms. …

In other words, many of the AYAs and their families had been navigating multiple challenges and stressors before gender dysphoria and transgender-identification became part of their lives. This context could possibly contribute to friction between parent and child and these complex, overlapping difficulties as well as experiences of same-sex attraction may also be influential in the development of a transgender identification for some of these AYAs. …

However, it is plausible that the following can be initiated, magnified, spread, and maintained via the mechanisms of social and peer contagion: (1) the belief that non-specific symptoms (including the symptoms associated with trauma, symptoms of psychiatric problems, and symptoms that are part of normal puberty) should be perceived as gender dysphoria and their presence as proof of being transgender … The spread of these beliefs could allow vulnerable AYAs to misinterpret their emotions, incorrectly believe themselves to be transgender and in need of transition, and then inappropriately reject all information that is contrary to these beliefs. In other words, “gender dysphoria” may be used as a catch-all explanation for any kind of distress, psychological pain, and discomfort that an AYA is feeling while transition is being promoted as a cure-all solution….

Transition as a drive to escape one’s gender/sex, emotions, or difficult realities might also be considered when the drive to transition arises after a sex or gender-related trauma or within the context of significant psychiatric symptoms and decline in ability to function. Although trauma and psychiatric disorders are not specific for the development of gender dysphoria, these experiences may leave a person in psychological pain and in search of a coping mechanism.

But just what are these mental health conditions, trauma, and other “stressors” that are leading these youth to believe they’re trans? What, exactly, would cause that? Littman’s answer appears to be: just about anything under the sun. These include depression and anxiety:

Another participant said, “My daughter saw a child therapist and the therapist was preparing to support transgendering and did not explore the depression and anxiety or previous trauma.”

Sexual trauma:

One parent described. “Her current therapist seems to accept her self diagnosis of gender dysphoria and follows what she says without seeming too much interested in exploring the sexual trauma in her past.”

Autism spectrum disorders:

Another parent wrote, “The Asperger psychiatrist did not seem to care whether our daughter’s gender dysphoria stemmed from Asperger’s. If our daughter wanted to be male, then that was enough.”

“Gender related trauma”, parents divorcing, the death of a parent, or mental health conditions in other family members:

Before the onset of their gender dysphoria, many of the AYAs had been diagnosed with at least one mental health disorder or neurodevelopmental disability and many had experienced a traumatic or stressful event. Experiencing a sex or gender related trauma was not uncommon, nor was experiencing a family stressor (such as parental divorce, death of a parent, or a mental health disorder in a sibling or parent).

Rape, attempted rape, sexual harassment, abusive romantic relationships, experiencing a breakup, bullying, social isolation, moving, or changing schools:

Many (48.4%) had experienced a traumatic or stressful event prior to the onset of their gender dysphoria. Open text descriptions of trauma were categorized as “family” (including parental divorce, death of a parent, mental disorder in a sibling or parent), “sex or gender related” (such as rape, attempted rape, sexual harassment, abusive dating relationship, break-up), “social” (such as bullying, social isolation), “moving” (family relocation or change of schools); “psychiatric” (such as psychiatric hospitalization), and medical (such as serious illness or medical hospitalization).

Other mental health conditions or neurodevelopmental disabilities mentioned in the survey responses include ADHD, OCD, eating disorders, bipolar disorder, and psychosis. The most obvious issue with this vast array of conditions or events being cited as reasons why a trans youth’s gender dysphoria may not be genuine is that, taken together, these supposed “causes” are all very common:

As the number of proposed “alternative causes” of gender dysphoria multiplies, so do the theoretical gaps: the “rapid onset gender dysphoria” hypothesis must now explain the mechanisms by which each of dozens of issues would produce gender-dysphoric symptoms. How does sexual harassment cause gender dysphoria? How does moving or changing schools cause gender dysphoria? How do breakups cause gender dysphoria? All of these different circumstances are so common that if they were a significant contributor to the development of dysphoria, far more than a mere 0.6% of the population would be trans.

But this is only puzzling if we assume that the intention of the “rapid onset gender dysphoria” hypothesis is to offer real and substantive explanations for how all of these things could happen. More likely, this doesn’t make sense as an explanation because it doesn’t have to make sense as an explanation, and probably isn’t meant to at all.

Instead, what we see here is an offering of pseudoexplanations that serve a distinctly different purpose. Take any individual trans kid, and the odds are favorable that you can find one or more of these conditions or events in their background – particularly given the highly elevated rates of mental health conditions among trans people. This proliferation of alleged causes does make sense as a deliberate strategy to reach for any possible excuse for why a trans youth’s gender dysphoria is not genuine, and apply this invalidation to nearly any trans youth, as seen in the demand by parents that clinicians look for any other possible “alternative cause” rather than accepting that these youth are simply trans.

This is consistent with the approach recommended by other proponents of ROGD, such as “Parents of ROGD Kids”, who call for “careful, in-depth psychological assessment” to uncover “the root causes of gender dysphoria” – “a long and difficult process, as the roots can be buried deep in the subconscious”. In this way, the search for some “alternative cause” can continue without end – and gender-affirming treatment can be delayed indefinitely.

Littman is critical elsewhere of “vague signs and symptoms called signs of GD”. She does not appear to have applied this critical perspective when vague signs and symptoms are called signs of ROGD.

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“Rapid onset gender dysphoria” study: On “recent” changes in sex ratios

Zinnia JonesDemographic changes in recent years toward a predominance of adolescent AFABs presenting for gender dysphoria evaluation and treatment have been frequently touted by proponents of the “rapid onset gender dysphoria” condition, who often infer that such an increase must be indicative of an entirely new syndrome afflicting this group specifically. In the full “rapid onset gender dysphoria” study, published this month, study author Lisa Littman offers this speculation:

This research sample of AYAs also differs from the general population in that it is predominantly natal female, white, and has an over-representation of individuals who are academically gifted, non-heterosexual, and are offspring of parents with high educational attainment [41–43]. The sex ratio favoring natal females is consistent with recent changes in the population of individuals seeking care for gender dysphoria. Gender clinics have reported substantial increases in referrals for adolescents with a change in the sex ratio of patients moving from predominantly natal males seeking care for gender dysphoria to predominantly natal females [19, 44–46]. Although a decrease in stigma for transgender individuals might explain some of the rise in the numbers of adolescents presenting for care, it would not directly explain the inversion of the sex ratio. It is plausible that rapid-onset of gender dysphoria may have some similarities to anorexia nervosa and the characteristics that make female adolescents more susceptible than male adolescents to anorexia nervosa may be the same characteristics that make natal females more susceptible than natal males to rapid-onset gender dysphoria.

Those presenting this shift in sex ratios as due to the emergence of a new condition such as “rapid onset gender dysphoria” often depict such a shift as being entirely unheard of and never before observed. But as evidence from several decades indicates, there is no universal baseline sex ratio that is being deviated from here – sex ratios of adolescent and adult gender dysphoria have often favored either trans men or trans women in different countries over different time periods, with those sex ratios frequently showing substantial shifts.

To get an idea of these known variations, consider the following findings:

  • Bakker et al. (1993) found a sex ratio in the Netherlands of 2.5:1 trans women to trans men.
  • Olsson & Möller (2003) reported a sex ratio in Sweden of about 1:1 in the late 1960s, shifting to about 2:1 trans women to trans men in the 1990s.
  • Garrels et al. (2001) observed a sex ratio in Germany of 2:1 trans women to trans men from 1970 to 1994. However, after 1994, this shifted to a ratio of 1.2:1 trans women to trans men.
  • Godlewski (1988) reported that over six years, the sex ratio in Poland remained constant at 5.5:1 trans men to trans women.
  • Wilson et al. (1999) found a sex ratio in Scotland of 4:1 trans women to trans men.
  • Tsoi (1998) found a sex ratio in Singapore of about 3:1 trans women to trans men.
  • De Cuypere et al. (2007) reported a sex ratio in Belgium of 2.43:1 trans women to trans men.
  • Vujovic et al. (2009) observed a sex ratio of 1:1 in Serbia, remaining constant over 20 years.
  • Cohen-Kettenis & Gooren (1999) reported a sex ratio in Poland and Czechslovakia of 5:1 trans men to trans women.
  • Okabe et al. (2008) reported a sex ratio in Japan of about 1.5:1 trans men to trans women.
  • Veale (2008) reported a sex ratio in New Zealand of 6:1 trans women to trans men.

The problem with a sex ratio argument for “rapid onset gender dysphoria” is that it proves too much. If shifts in sex ratio are indicative of the emergence of a new condition, then on that same basis, we could claim that any number of such new gender dysphoria syndromes have been afflicting various populations throughout history. Were AFABs in Poland and Czechslovakia succumbing to “rapid onset gender dysphoria” in the 1980s? Is Japan currently experiencing such an epidemic as well, resulting in a predominance of trans men? Did “rapid onset gender dysphoria” strike in Germany after 1994, leading to a nearly equal sex ratio where this ratio was 2:1 in favor of trans women before? What about Sweden – after the 1960s, did some new kind of gender dysphoria begin to afflict AMABs, resulting in a shift from a 1:1 ratio to a 2:1 ratio favoring trans women?

And if it was not necessary to propose new gender dysphoria syndromes to account for these known historical demographic changes, why is it necessary to propose “rapid onset gender dysphoria” to account for this now?

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