The term ‘gender identity’ originated in the 1950’s and 60’s with the work of clinicians in the field of sexology, including Robert Stoller, Harry Benjamin and John Money. Their attempts to define ‘gender identity’ included child psychoanalysis and surgical reassignment.
No good evidence exists to support the proposition that a sense of gender identity is innate (although it would be hard to prove either way). While the experience of those who say they were born with a gender identity is deeply-felt (thus real to those individuals) and aligns with current messages on this topic in wider society, the concept of gender identity has far more in common with socio-cultural constructs, rather than biological characteristics. If that is the case it cannot, by definition, be innate. However, there are also suggestions that there may exist some innate biological marker of gender (the hypothesis is that there may be a kind of ‘brain sex’, which can differ from the rest of the body’s ‘somatic sex’) and yet on the other hand that gender identity is fluid, self-identified and purely subjective. How and why might these propositions have come about? What are the consequences for clinicians?
Until recently, the standard consensus has been that we gain self-awareness as children and young people of our sex and other bodily characteristics, as well as our abilities, attributes and character, as part of natural development that unfolds inexorably with time and interacts with family, school and community. An emerging, contrasting, view is that people are born with an innate sense of ‘gender identity’. For example, the website for GIRES, a well-known lobby group which has advised UK Government agencies such as the Office for National Statistics on how to define ‘gender’, contains a pdf information sheet depicting non-identical, dizygotic twins in utero, with a legend explaining that each fetus “identifies” either as a boy and a girl (GIRES, 2016).
The term ‘gender identity’ originated in the 1950’s and 60’s with the work of clinicians in the field of sexology, including Robert Stoller, Harry Benjamin and John Money. Their attempts to define ‘gender identity’ included child psychoanalysis and surgical reassignment. An especially notorious outcome of Money’s work was the ethically dubious, and ultimately tragic, case of David Reimer. Reimer (Bruce/ David/ Brenda) was a boy who was raised as a girl following a botched circumcision in infancy involving catastrophic cautery to his penis. He subsequently underwent years of clinical follow-up consisting of serial psychological ‘evaluations’ which, in modern clinical practice, would be characterised not only as unethical but also sexually and emotionally abusive (InterACT, 2013). This case has sometimes been cited as evidence for the existence of an innate sense of gender identity, but it should be noted that if David Reimer had a gender identity, it was with his original male biological sex.
The idea that gender identity is fluid has its roots in post-modern philosophy, as exemplified in the writings of French philosophers Michel Foucault and Jacques Derrida, and later interpretations of these works by the American philosopher and feminist Judith Butler. Put simply, post-modernism proposes that our ways of understanding the world need to be ‘deconstructed’, and conventional boundaries need to be broken, in order to expose the multiple oppressions inherent in traditionally accepted knowledge structures, including science and medical science. Post-modernism privileges the subjective over the objective, the emotional over the rational. It holds that language shapes our understanding of what we experience as being reality to an extreme degree, with words having extraordinary power. According to Butler, gender is ‘performative’, by which she means that it comes about as a result of acts rather than representing who someone is (Butler, 2006). In this sense, her definition corresponds to the notion of gender as socially constructed, rather than innate.
The proposition that a sense of ‘gender identity’ is inborn rather than socially constructed is held by some. Various studies have attempted to show how the brains of those identifying as transgender are different (Savic, Garcia-Falgueras and Swaab, 2010; Bao and Swaab, 2011). Such studies are often confounded and inconsistent, or show small differences that are in the form of associations. They do not prove that a pre-existing innate gender leads to an individual identifying as transgender. The conclusions of those papers and their methodology have been criticised elsewhere in the scientific literature (Joel et al., 2015; Eliot et al., 2021).
The idea of an innate inborn gender might appear to depart from its post-modern roots, but it has been arrived at as an extension of post-modernism and as a result of the mainstreaming of post-modern ideology across almost all aspects of early twenty-first century society especially, perhaps, in the USA and the UK. Numerous online sites and fora promote information about the multiplicity of possible gendered selves, and educational materials are made widely available to schools, healthcare and other public institutions, to further disseminate these ideas (Gendered Intelligence, no date; Killerman, 2017).
If nothing about a person’s body is fixed or immutable, if all boundaries are there to be taken down, and if subjective experience is paramount, then anyone, regardless of their physical body, can confidently state “I feel like a woman (or man)” or indeed “I am a woman (or man)”. Or “I am agender” (or one or more of many varieties of nonbinary gender identities, where a person identifies as neither woman nor man, or both at the same time, or switches between identities). Where such feelings are strongly present, and where the inner sense of gender identity conflicts with biological sex, then the subjective sense of gender identity (a feeling) is taken to represent the person’s ‘true self’, rather than their objective sex (a bodily attribute). This self-identified ‘true self’ then takes precedence over bodily form; ‘sex’ is described as being ‘assigned’, thus gender identity supplants (as opposed to supplements) empirically observed reality. The name for the physical body is thereby downgraded to something that can be dismissed as ‘reductionist,’ acting to “privilege biology” over a person’s “lived and felt identity.” (GIDS, no date) Naming biological sex becomes reconceived as a purely arbitrary act performed by bureaucratic doctors and midwives that takes no note of the individual’s invisible, immeasurable, unquantifiable essence of femininity or masculinity, which, it is concluded, although indefinable, is internal and innate.
Important consequences follow from this reasoning, some political and legal, others clinical. They will be relevant to health professionals, who are increasingly expected to offer invasive and life-changing medical and surgical interventions on the physical bodies of patients coming to clinic with the assertion that their body does not represent who they feel themselves to really be. Such clinical situations are not based on usual medical evidence applied to well-understood and researched phenomena of diseases or disorders. Instead, they are the logical sequelae of following the theory of gender identity:
First, a hierarchy is created, in which the physical body ranks lower than a subjective, innate sense of identity. The body can then be manipulated by hormones and adapted by surgery so that it conforms to the inner sense of what is ‘real’. A patient can expect to be ‘treated’ (with that word’s inherent implication of an intelligible cause-to-consequence benefit) in order to restore them to their ‘true self’, a state that the body they were born with has allegedly denied them. Such conceptualisations encourage clinicians to give people with demonstrably ‘healthy’ bodies hormones and surgery, in the name of what the patient has deemed as their ‘natural’ sense of inner gender. Thus there is a reversal of the clinical significance of objective and subjective facts about a patient. The scientifically measurable and observable element (biological sex) is downplayed in favour of the intangible, someone’s verbal assertion of their internal self-perception. The downplaying of the relevance of the physical body in a healthcare setting is especially concerning if the usual quantification of benefits, risks and possible harms of medical interventions like hormones (Haupt et al., 2020) are under-explored by the scientific literature.
Second, if it is asserted that an individual’s gender identity is innate, natural and, crucially, subjective and therefore self-determined, then it can never be objectively measured, quantified, challenged, proven or disproven. Any requests or demands that might follow from a declaration of gender identity, such as for medical interventions, can be claimed as needing to be met without question. Therefore advocates in favour of gender identity theory may work to persuade political parties, public and private institutions to change various practices or laws. For example, the post-modern notion of the power of language is used to suggest that people within healthcare, educational, workplace or other settings should specify how they wish to be addressed in terms of their pronouns (so to call someone she or him or they or zie, etc). A failure to adhere to the pronouns others have specified may risk accusations of ‘misgendering’. While sex and gender identity are classically thought of as separate concepts, for some proponents of the idea of innate gender identity, self-declaration supplants sex completely as the necessary criterion for what makes a person female or male. On that view, objective biological sex can become discounted completely, as otherwise there would be competition regarding definitions of femaleness or maleness. Thus, gender identity is not merely additive, or complementary to sex, even though definitions of gender identity are usually framed in relation to bodily form, and often in contrast to the physical body (for example, gender identity is defined as a self-identification that either ‘matches’ or does not ‘align with’ biological sex).
Third, any psychological therapy offered to persons who suffer from psychological discomfort or distress in relation to their subjective sense of gender identity must ‘affirm’ (in the sense of ‘confirm’ or ‘promise’) this sense of identity, rather than attempt to empathise with the distress and explore it. Usually, exploration of a person’s presenting distress is the cornerstone or starting point of all mainstream, evidence-based models of psychotherapy. Accepting a view that presents a subjective sense of identity as innate and immutable potentially inhibits any form of exploration of a patient’s emotions, motives, thoughts and other mental processes that underlie their behaviours and may be linked with how they perceive themselves. To discuss and explore might even be deemed ‘conversion therapy’ (see FAQ What is Conversion Therapy, and what is the Memorandum of Understanding?). If warm, neutral, supportive interactions may start to become labelled as unacceptable for clinicians to engage in, because they follow usual standards for exploration, then this would run counter to the principles of good psychological therapy and potentially deprive patients with gender identity issues of sufficient support. This is particularly concerning for those patients who may have been through traumatic events, such as sexual abuse as children, when they did not have power or words to understand their experiences. Later, they may develop complicated emotions around their own bodies, feelings towards themselves and other people, and identity. A compassionate clinician should be open to and accepting of complexity, building a relationship with the patient and listening carefully, instead of committing to ‘affirming’ only one possible interpretation of a patient’s feelings.
Fourth, if subjective gender identity is conceptualised as innate and immutable (and therefore the only, or best, recourse for a person is to change their physical body to try to fit it to their inner sense of themselves) then any questioning of such assertions may become characterised as abusive, persecutory or discriminatory. Health care professionals critically examining the tenets and evidence about gender identity theory, and its associated medical practices, might be labelled as engaging in hateful and bigoted conduct, or even causing harm. While a minority of clinicians may be clumsy or acting against the best interests of patients, most are good-willed. Fear of accusations of doing wrong may put clinicians off from engaging in this space, or cause them to refrain from applying the usual principles of ethical healthcare practice. If fewer clinicians are scrutinising evidence around gender identity (for example, actively looking for safety and effectiveness or long-term effects of interventions), paradoxically this may result in poorer healthcare for patients seeking to change their body to match their inner sense of self, as the assumptions and work of peers might remain relatively unexamined and undergo less rigorous scrutiny than other fields of clinical practice. Normally, the self-correcting disciplines of science and medicine are improved by ‘the many eyes’ looking critically, which should be seen as a ‘gift’ rather than be assumed as hostile. Respectful or nuanced discourse and debate requires a commitment to respect from all parties.
References:
Bao, A.-M. and Swaab, D. F. (2011) ‘Sexual differentiation of the human brain: Relation to gender identity, sexual orientation and neuropsychiatric disorders’, Frontiers in Neuroendocrinology, 32(2), pp. 214–226. doi: 10.1016/j.yfrne.2011.02.007.
Butler, J. (2006) Gender Trouble: Feminism and the Subversion of Identity. Routledge.
Eliot, L. et al. (2021) ‘Dump the “dimorphism”: Comprehensive synthesis of human brain studies reveals few male-female differences beyond size’, Neuroscience & Biobehavioral Reviews, 125, pp. 667–697. doi: 10.1016/j.neubiorev.2021.02.026.
Gendered Intelligence (no date) Trans Identities, Genderedintelligence.co.uk. Available at: https://genderedintelligence.co.uk/projects/kip/transidentities.html.
GIDS (no date) Glossary. Gender Identity Development Service. Available at: https://gids.nhs.uk/glossary
GIRES (2016) Transgender Experiences – Information and Support for trans, non-binary and non-gender people, GIRES.org.uk. Available at: https://www.gires.org.uk/transgender-experiences-information-and-support-for-trans-non-binary-and-non-gender-people/.
Haupt, C. et al. (2020) ‘Antiandrogen or estradiol treatment or both during hormone therapy in transitioning transgender women’, Cochrane Database of Systematic Reviews. doi: 10.1002/14651858.CD013138.pub2.
InterACT (2013) David Reimer, Honor and Remember Him, Interactadvocates.org. Available at: https://interactadvocates.org/david-reimer-honor-and-remember-him/.
Joel, D. et al. (2015) ‘Sex beyond the genitalia: The human brain mosaic’, Proceedings of the National Academy of Sciences, 112(50), pp. 15468–15473. doi: 10.1073/pnas.1509654112.
Killerman, S. (2017) The Genderbread Person v 4, itspronouncedmetrosexual.com. Available at: https://www.itspronouncedmetrosexual.com/2018/10/the-genderbread-person-v4/.
Savic, I., Garcia-Falgueras, A. and Swaab, D. F. (2010) ‘Sexual differentiation of the human brain in relation to gender identity and sexual orientation’, in, pp. 41–62. doi: 10.1016/B978-0-444-53630-3.00004-X.