Seeing Transgender People

March 31st of each year is Transgender Day of Visibility around the world. For many of us in the cisgender majority [1] , the transgender community has been so hidden in the past as to be invisible. Despite this, transgender people have been documented in virtually every society since ancient times and they were often more accepted than they are in the present day.

Invisibility is one of the consequences of the stigma and discrimination faced by transgender individuals. Modern society has emphasized fitting in and conforming to specific ideals in a way that pressures people to deny or hide the ways they differ from the accepted stereotypes. Refusing to conform results in shaming, ostracization, and even violence. And these feelings are frequently turned inward, leading to incredibly high rates of anxiety, depression, suicidal ideation, suicide attempts, and completed suicide among the transgender community.

An older friend on Facebook once challenged me with the question, “Where were all the transgender people when I was younger?” I pointed out that it’s always easy to miss the differences people hide, especially when you don’t realize they’re there or are told they don’t exist. When she pressed me on the point, I responded, “Those who couldn’t hide it likely killed themselves.” She didn’t reply to that.[2]

Transgender children

I’m not an expert in the treatment of transgender individuals, but I have worked as a child psychologist with families coming to terms with children who were transgender. Those families have included children who declared to their parents that they were the other gender when they were as young as three years old.

Regardless of how old they were when they first announced to others that they were not the gender everyone seemed to think they were, they made this as a statement of fact from their perspective. “Everyone thinks I’m a boy, but I’m not. I’m a girl.” “Stop calling me ‘her.’ I’m a boy.”

Not surprisingly, this type of assertion is extremely difficult for parents to hear. Leaving aside the social and conformist issues for a moment, it’s bewildering to have your child express such a fundamental element of their identity that contradicts what you’ve thought about them since birth. For those of us whose sex assigned at birth aligns with our identity, gender is a basic, visible reality of our experience and it’s disorienting to hear someone close to us dispute what we thought was clear.

That may also force parents to reconsider their expectations and future hopes for their child. Although we all know we shouldn’t pin our dreams on our kids, it can be painful to realize that a future we envisioned may never come.

Returning to the social issues, and particularly the price we pay for not conforming to social norms, parents of transgender children usually realize almost immediately that their child is likely to face tremendous challenges because of this. One parent told me, “I can accept that he’s now my son, but it breaks my heart knowing how difficult that will make his life and how many people will judge and reject him for just being himself.” Despite the stories in the media, I’ve never met a parent of a transgender child who actively encouraged a transgender identity before the child expressed one themselves. Another parent once said to me, “I would never have chosen this for my child.”

The psychology of transgender identity

Although many people seem to believe the term “biological sex” is clear and precise, the opposite is the case. Our biological sex is determined not just by chromosomes[3] , but by epigenetic factors – nongenetic influences on how our genes are expressed – including hormones, internal and external physiology, and environmental and social influences. At a biological level, sex is not binary and there is no scientific basis for acting as if it is.[4]

Further, more than 1% of the population is born with intersex traits; that is, their reproductive anatomy doesn’t match the male-female dichotomy. The number of intersex individuals increases when you include people whose chromosomal and/or hormonal makeup are inconsistent with the binary. Those people do not physically conform with our moral opinions on gender.

When others have quoted Genesis 5:2 to me, I’ve asked, “What about people who have both male and female genitals?” I’ve yet to get a clear answer on that. I don’t mean to get into a theological debate with anyone, but it’s difficult for me to accept a theological position that denies the very existence of more than 1 out of every 100 people. They don’t fit the narrative, but they exist, nonetheless.

When I was in graduate school, “Transsexualism” was a formal psychiatric diagnosis in the category of Psychosexual Disorders applied to adolescents and adults, and Gender Identity Disorder of Childhood was the equivalent diagnosis for children. This was progress from the days when homosexuality was classified as a “sociopathic personality disturbance,” but my LGBTQ+ friends and colleagues were adamant, even back in the early 1980s, that pathologizing gender expression and consensual sexual relationships was both unscientific and harmful.

Subsequent research has strongly confirmed my friends’ beliefs: enforcing artificial gender stereotypes on transgender individuals is extremely hurtful. It contributes to a range of problems, not the least being incredibly high rates of suicidality.

In therapy with families including a transgender child, one of the first things I do is clarify for the parents that this isn’t something they caused through their actions. Mothers don’t cause sons to choose a transgender identity by coddling them; fathers don’t push daughters to become transgender by treating them as tomboys. Most of the parents I’ve worked with have felt guilt and shame, as if they did something that caused their child to choose a different gender identity; when I ask them if anyone could have led them to “choose” a different gender identity themselves, however, they immediately recognize that the concern is unrealistic. As parents, we wield tremendous influence over our children, but there are limits.

The second thing I do is explore the choice the parents face. From their perspective, they virtually always describe this as having to choose between trying to control and stop a development that they experience as innate within their child versus accepting what seems inevitable. The former path would require them to consistently discourage or even punish transgender expressions – what their child calls themselves, how they dress, how they play, virtually everything. There are a lot of controversies and unknowns in the research on transgender children, but one thing is clear: attempting to force a child to abandon their belief in being transgender is usually actively harmful to the child.

Beyond that, I refer these families to a specialist. I’m not qualified to advise them on how and when to support social transitioning, such as decisions about pronouns, names, and clothing. And, as a psychologist, I have no training or experience in the medical processes associated with transitioning.

Transgender adults

There’s much less controversy when it comes to transgender adults. Most people who have transitioned to match their gender identity are positive about it: they have lower rates of anxiety, depression, substance use, and suicidality than self-identified transgender people who have not transitioned. They report higher self-esteem, better quality of life, and increased satisfaction in their relationships. They acknowledge the difficulties being transgender brings in our society, but they typically see those as a problem with the culture, not with them.

My hope for our culture is that we can finally see these people and recognize that denying their reality is to condemn them. There are many things in life I don’t understand and I’m no expert on this topic, but I often think of what a friend once told me when she was discussing her trans daughter:

“The way I see it, I have a choice between accepting her as she is or rejecting her, but that’s really not even a choice. I love her. I have to accept her.”

There are countless ways we can be allies for transgender people – respecting their terminology when they describe themselves, using the name and pronouns they use, supporting inclusive policies and gender-neutral bathrooms, and, above all, listening to them – but it all starts with seeing them for the individuals they are. After decades of invisibility, I think that’s the least we can do.

To learn more, visit https://www.kqed.org/futureofyou/440851/can-you-really-know-that-a-3-year-old-is-transgender and https://www.glaad.org/transgender/allies .

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This piece is not intended as medical or legal advice. Always speak with your medical provider before initiating a diet or exercise regimen or if you have medical questions. If you have legal questions, consult with an attorney.

This article represents my own opinions as a non-physician and does not reflect the opinions or positions of my employer.

[1] Cisgender individuals are people whose internal sense of their own gender, their gender identity, aligns with the gender they were assigned at birth, generally based on their physical anatomy. Transgender individuals are people whose gender identities are different from the gender they were assigned at birth.

[2] Ironically, this friend was born in 1930, the same year Lili Elbe received the first well-known male-to-female gender confirmation surgery; the first documented gender confirmation surgery involved Dora Richter in 1922.

[3] The most common chromosomal patterns, the ones many of us learned in school, are XX and XY, but other variations are common, although only rarely diagnosed. Those include XXY, XYY, XXX and X.

[4] https://blogs.scientificamerican.com/voices/stop-using-phony-science-to-justify-transphobia/