Most people’s gender identity – their self-perception of being male or female – aligns with their biological sex. According to the 2021 census, 99.7% of Canadians aged 15 years and older affirm that their internalized gender identity matches their biological sex (Statistics Canada). A small minority of people – the remaining 0.33% of Canadians – experience gender dysphoria.
Gender dysphoria is a condition in which a person’s gender identity does not match their sex (see note). For example, someone who is a biological female may feel that she is, or should be, male. Gender dysphoria, a psychological phenomenon, is not to be confused with biological disorders of sexual development, which are even more rare.
While there is no single, generally accepted cause for gender dysphoria, there are discernible trends among children and adolescents with gender dysphoria. Among children who exhibit gender dysphoria prior to puberty, approximately 80% will “desist” or out-grow this dysphoria by adulthood.* However, the number of post-pubescent adolescents – teenage girls in particular – with gender dysphoria has skyrocketed in western countries like Canada, the United States, and the United Kingdom in recent years. Researchers have called this phenomenon rapid-onset gender dysphoria and some suggest that it is a social contagion.**
Among children who exhibit gender dysphoria prior to puberty, approximately 80% will “desist” or out-grow this dysphoria by adulthood.
The current Canadian approach to treating gender dysphoria is called, euphemistically, gender-affirming care. This approach to care is described in the World Professional Association on Transgender Health (WPATH)’s Standards of Care. Canadian provinces generally follow these WPATH standards, albeit with significant differences between provinces. Regulatory colleges recommend or require this approach. Under this approach, when a child or adolescent reaches out to a health practitioner about gender dysphoria, the practitioner affirms the patient’s self-perceived gender identity and seeks to change the patient’s body to appear more like the desired sex.
In other words, unlike in other areas of medicine, gender clinicians typically agree with patients’ (or, in the case of young children, their parents’) self-diagnosis of gender dysphoria and refer for treatment on the basis of this self-diagnosis. The clinician doesn’t perform any tests to diagnose gender dysphoria. The clinician can’t encourage a child to think of themselves or act in a way that corresponds with their birth sex – that’s illegal under Canada’s ban on conversion therapy. Under the paradigm of gender-affirming care, there is only one acceptable treatment direction: onward to a medical and/or surgical transition.
According to WPATH’s standards, medical practitioners should only proceed to gender-affirming medical and surgical treatment for minors if:
- Gender dysphoria is marked and sustained over time;
- The diagnostic criteria of gender dysphoria are met (as per International Classification of Diseases 11)11;
- The patient demonstrates the emotional and cognitive maturity required to provide informed consent;
- Mental health concerns (if any) have been addressed;
- The patient has been informed of the effects of treatment on reproduction;
- The patient has reached Tanner stage 2 of puberty (the beginning of the physical stages of puberty) for puberty blockers and cross-sex hormones; and
- The patient has received at least 12 months of gender-affirming hormone therapy (before gender reassignment surgery can be performed).***
The fundamental problem with gender-affirming care is that it misdiagnoses the problem. Gender dysphoria is not a problem of the body. While gender identity and gender expression can change over the course of someone’s lifetime, biological sex cannot change.
“The fundamental problem with gender-affirming care is that it misdiagnoses the problem.”
True, hormone injections can trigger the development of secondary sex characteristics (e.g. facial hair, lower voice, or an Adam’s apple). And surgical procedures can remove or create imitations of reproductive organs. However, hormones and surgeries cannot change the fundamental sexual organization of the human body as male or female.
A person’s sex is objectively determined by the organization of their body for a specific reproductive role – to produce sperm cells (male gametes) or egg cells (female gametes), as evidenced by the person’s sex chromosomes, naturally occurring sex hormones, and internal and external genitalia. Aside from extremely rare genetic disorders, each cell in a person’s body has either an XY chromosome (male) or an XX chromosome (female). In short, while these gender transition surgeries are often called “sex change surgeries,” such a term is a misnomer because it’s impossible to change your biological sex.
Gender-affirming care assumes that the fundamental problem is that a person is born into the wrong body. By getting the problem wrong, it also gets the solution wrong. Its misguided solution to gender dysphoria is to radically reshape the body, at great cost to physical health (more on that in a future post).
“The solution is not to radically reshape the body through drugs, hormones, and surgery. The solution is to help someone accept and love their natural body. ”
The problem of gender dysphoria does not lie with the body. It lies with the mind. Those who experience gender dysphoria have nothing wrong with their body. Rather, they have difficulty identifying with or accepting their body. That is a real and very difficult struggle. But the solution is not to radically reshape the body through drugs, hormones, and surgery. The solution is to help someone accept and love their natural body.
In a review of Johns Hopkins University’s “sex change” clinic, former director Dr. Paul McHugh states that “in a thousand subtle ways, the re-assignee has the bitter experience that he is not — and never will be — a real girl but is, at best, a convincing simulated female. Such an adjustment cannot compensate for the tragedy of having lost all chance to be male, and of having in the final analysis, no way to be really female.”1
Dr. Sander Breiner agrees, explaining that she and her colleagues at Michigan’s Wayne State University had to tell the surgeons that “the disturbed body image was not an organic [problem] at all, but was strictly a psychological problem. It could not be solved by organic manipulation (surgery, hormones).”2
It is common today for people to speak of being a woman trapped in a man’s body or a man trapped in a woman’s body. But, as Toronto psychiatrist Dr. Joseph Berger explains, “scientifically, there is no such thing.”3
Note:
There are a variety of words used to describe this phenomenon. ARPA Canada prefers the term “gender dysphoria,” found in the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders V. The International Classification of diseases uses “gender incongruence,” WPATH prefers the term “transgender and gender diverse people,” while the vernacular defaults to the descriptor “transgender.”
Sources:
* See for example Thomas D. Steensma and Peggy T. Cohen-Kettenis, “A Critical Commentary on ‘A Critical Commentary on Follow-up Studies and “Desistence” Theories about Transgender and Gender Non-Conforming Children,’” International Journal of Transgenderism 19, no. 2 (April 3, 2018): 225–30; Thomas Steensma and Peggy Cohen-Kettenis, “Gender Transitioning before Puberty?,” Archives of Sexual Behavior 40 (March 1, 2011): 649–50; Thomas D. Steensma et al., “Desisting and Persisting Gender Dysphoria after Childhood: A Qualitative Follow-up Study,” Clinical Child Psychology and Psychiatry 16, no. 4 (October 1, 2011): 499–516; Kelley D. Drummond et al., “A Follow-up Study of Girls with Gender Identity Disorder,” Developmental Psychology 44 (2008): 34–45; Madeleine S. C. Wallien and Peggy T. Cohen-Kettenis, “Psychosexual Outcome of Gender-Dysphoric Children,” Journal of the American Academy of Child and Adolescent Psychiatry 47, no. 12 (Dec 2008): 1413–23; Susan J. Bradley and Kenneth J. Zucker, “Gender Identity Disorder and Psychosexual Problems in Children and Adolescents,” The Canadian Journal of Psychiatry 35, no. 6 (August 1, 1990): 477–86; Jiska Ristori and Thomas D. Steensma, “Gender Dysphoria in Childhood,” International Review of Psychiatry 28, no. 1 (2016): 13–20; Devita Singh, Susan J. Bradley, and Kenneth J. Zucker, “A Follow-Up Study of Boys With Gender Identity Disorder,” Frontiers in Psychiatry 12 (2021).
** Lisa Littman, “Parent Reports of Adolescents and Young Adults Perceived to Show Signs of a Rapid Onset of Gender Dysphoria,” PLOS ONE 13, no. 8 (August 16, 2018): e0202330; Abigail Shrier, Irreversible Damage (New Jersey: Regnery Publishing, 2020).
*** Coleman et al., “Standards of Care for the Health of Transgender and Gender Diverse People, Version 8,” 18.
1. Dr. Paul McHugh is Distinguished Service Professor of Psychiatry at Johns Hopkins University. In 2004, Dr. McHugh published an article explaining the scientific reasons for rejecting sex change procedures. After describing the great deal of damage he witnessed from sex-reassignment, he concluded, “we psychiatrists have been distracted from studying the causes and natures of their mental misdirections by preparing them… for a life in the other sex. We have wasted scientific and technical resources and damaged our professional credibility by collaborating with madness rather than trying to study, cure, and ultimately prevent it.” Paul R. McHugh, “Surgical Sex: Why We Stopped Doing Sex Change Operations” (Nov. 2004) First Things.
2. Sander Breiner, M.D., “Transsexuality Explained,” National Association for Research and Therapy of Homosexuality, n.d., accessed March 26, 2015. Dr. Breiner also explained that “[T]he significance of the psychological difficulty should not be minimized by a patient’s seeming success, socially and professionally, in other areas”.
3. Written testimony of Dr. Joseph Berger to the House of Commons Standing Committee on Justice and Human Rights, regarding Bill C-279.