I was surprised by the rhetorical slight-of-hand attempted by New York Times opinion writer David French regarding the current Supreme Court case in which judges and politicians in Tennessee, most of whom lack medical training or relevant scientific expertise, have declared that they know more than local medical doctors about how best to care for patients.
Given the premise of the article, I wasn’t surprised that there would be an attempt to hoodwink readers. But I was surprised by the ineptness of that attempt.
French writes that the Tennessee ban of gender-affirming care in minors “includes the use of puberty blockers and cross-sex hormones.”
French never again mentions puberty blockers, yet claims that the motivation for the law is to protect minors, not to discriminate (which is a rather specious claim, as ACLU lawyer explains in the essay “Gender-Affirming Care & the Courts,” printed in the New York Review of Books.
And midway through the article, French quotes a court brief given by the State of Tennessee in support of the ban: “giving girls high doses of testosterone induces hyperandrogenism that can cause cliteromegaly, atrophy of the lining of the uterus and vagina, irreversible vocal cord changes, blood-cell disorders and increased risk of heart attack.”
This is all true. High doses of testosterone can and often do cause a variety of irreversible effects, including effects on a person’s voice, a person’s face shape, a person’s adult height, and more.
This is precisely why medical doctors prescribing gender-affirming care would prescribe puberty blockers to a minor.
With puberty blockers, a girl (who might have been assigned male at birth, because biological sex assignments are made based only on an assessment of a newborn’s external genitalia, whereas a person’s identity is rooted in their brain) can be protected from high doses of testosterone.
Puberty blockers are effective only in minors – after a person has already gone through puberty, this approach is not possible – and are used to protect a patient from potentially irreversible changes that would aggravate the mismatch between their brain and body.
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There have been patients who regretted their decision to receive gender-affirming care. But this is true for all the choices that we make in life – there is always a chance that we will wish that we had said or done something else, especially since we can have a full understanding of the negative consequences of the choice that we did make, but will have only a hazily imagined conception of the alternative future that we could have had. And this is especially true for medical decisions.
Earlier this year, I was running on a treadmill at the YMCA while an overhead television showed an Olympic tennis match. The player on the far side of the court hit a beautiful cross-court return. I lurched reflexively to the side to intercept it. The treadmill stayed in the same place, though, and its belt was still spinning at just over ten miles per hour. My knee was wrenched beneath my body, tearing the meniscus.
For the next week, I could barely walk – even getting myself out of bed was excruciatingly painful.
So I had to consider whether or not to get surgery. Sometimes these surgeries help people recover more quickly; for other patients, a meniscus surgery will actually accelerate degeneration and elevate the risk of early-onset arthritis. No matter what I chose, I might later regret that I hadn’t made the other decision.
Although it was very painful to try to get from place to place, as long as I was very careful and patient with myself, there wasn’t much risk that I would cause additional damage by waiting. I could give myself a few weeks and then, if it wasn’t improving, opt for surgery later.
I chose to wait.
In the case of gender-affirming care, though, there is not a choice between a potentially irreversible treatment and a conservative “wait and see” approach that preserves the patient’s options. It’s not at all as though a minor were seeking to get a permanent tattoo, and could be counseled to delay getting the tattoo until after turning eighteen.
For these individuals, delaying care is a potentially irreversible treatment, as I’ve written previously. Forcing a patient to wait until age eighteen before allowing gender-affirming care will subject that patient to the potentially irreversible hormone surge of puberty. Delaying treatments that are prescribed by the patient’s medical care team is not conservative, pragmatic, or judicious; it is cruel.
The intent of this legislation is to undermine the expertise of both the medical care team (who know more than politicians about the workings of a human body) and the patient (who knows more than anyone about the inner experience of being a person with that particular brain and body).
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At my poetry class in the county jail last week, we read Ross Gay’s poem “Thank You,” which you can find here.
This poem reckons with the contrast between constantly knowing that “all you love will turn to dust” alongside the simultaneous experience of being part of a world that offers us moments of pleasure and beauty. We might want to rail against the fleeting nature of it all. The ever present threat of death; the traumas and tragedies that we’ve already had to endure. The seeming futility of many of our actions.
And yet. “Do not raise your fist,” Gay writes. “Do not raise your small voice against it.”
“Say only, thank you.”
I really like this poem. And I think that the poem’s central conflict is especially relevant to the experience of people who are incarcerated. They are routinely subjected to inhumane treatment: days or weeks of twenty-three & one (meaning 23 hours each day locked into a cell with one other person, and only 1 hour in which they are able to move freely within the small cement enclosure with its steel tables bolted to the floor and access to showers or phones or the TV); months without the sun (jails are not required to offer time outdoors, like prisons are, and even when jail staff do have time to take people to the interior courtyard with its tall walls and its slim view of the sky through an overhead chain-link fence, it might be during the middle of the night); etc.
And yet, for all that, they are alive. We talked, and I asked about some of the things they are looking forward to. Seeing their families; petting their dogs; being able to cook for themselves again, or just chose what to eat and when to lie down for bed.
As though saying grace, we spent time discussing aspects of the world that they feel grateful for.
Gradually, our conversation turned toward the ways that they have seen the world change during their lifetimes. Things they think have gotten better, and things they feel have gotten more difficult, or worse.
One man shook his head and said, “Can’t even assume a person’s gender no more.”
Across the table, another man concurred: “It’s about science. Somebody has an XX or an XY, but that doesn’t even count anymore. And it’s the same people who have their yard signs saying ‘Science Is Real,’ but how can you get more real than that?”
As it happens – and you can read about this in great detail in Richard Prum’s Performance All the Way Down, which I recently reviewed for The American Biology Teacher – there are many ways that a person might present as a biological sex that does not match their chromosomal karyotype (a “karyotype” is a visual analysis of a person’s chromosomes).
There is a gene on the Y chromosome that is named the “sex-determining region of the Y,” or SRY, and it makes a protein that binds to other regions of chromosomal DNA, and those protein binding events will cause an increased production of other proteins. And if a person has uncommon gene sequences for any of the proteins in that whole cascade, that person might be assigned female at birth despite having an XY karyotype. And some humans have an X chromosome that has a functional copy of the SRY gene on it – these people, despite having an XX karyotype, will usually be assigned male at birth.
Additionally – as I stress throughout introductory biology courses – genes always manifest their effects within particular environments. A bacteria with a gene that allows it to harvest energy from sunlight won’t have any selective advantage if it’s living in the dark interior of an animal’s body. A bacteria with a “broken” gene that makes it unable to synthesize a certain amino acid will not have any selective disadvantage if that particular amino acid is plentiful in the environment.
The fetal environment, including all the various hormones and chemicals present in the womb, will have a huge impact on the way that any given set of genes contribute to a person’s development.
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I agree with the men in jail: it does seem like more people are transgender now than in the past.
Part of that is cultural. Our society has become more accepting.
There have always been people who were transgender. The Talmud discusses seven distinct presentations of biological sex; Native American societies recognized some people as “two-spirit,” distinct from either men or women; many cultures preserved stories of a few exceptional individuals who lived in ways that defied expectations for someone who had been assigned their biological sex – and in a more accepting society, there is less risk of being publicly known as such.
And there have always been people who were intersex. Fetal development, including the development of genitalia, depends on genes found on many chromosomes, not just the X and Y chromosomes, and there are myriad distinct alleles that can influence this process. Indeed, evolution by natural selection generally requires that a variety of alleles be present in a population, which will usually result in a spectrum of traits being seen among the individuals of that population. In the past, medical doctors simply performed immediate, irreversible surgeries to “correct” the biological presentation of intersex individuals.
I think it’s good that our culture has become more accepting. Some people think it’s bad. But in any case, this is probably not the entire explanation for why transgender people seem more prevalent now.
The world is physically different than it used to be. Specifically, fetal development now occurs in the presence of a large number of novel chemicals, many of which are known to be endocrine disruptors in other animal species. Endocrine disruptors are chemicals in the environment that interact with hormones and other cell signaling pathways, and these chemicals can cause changes in development, behavior, metabolism, fertility, neurology, and more.
Maybe you’ve heard about chemicals that can cause male frogs to lay eggs? Even if the chemicals are at really low doses, like levels that the EPA has declared to be safe and acceptable for dumping into lakes or rivers. Those are endocrine disruptors.
Nearly 1,500 of the manufactured chemicals that humans are routinely exposed to are suspected to be endocrine disruptors, and thousands of new chemicals (some of which may also be endocrine disruptors) enter the commercial market each year after rather minimal safety testing.
We do not understand the effects of these chemicals on human health. We don’t know what exposure to these chemicals will do to a developing fetus; we obviously know even less about what effect these chemicals might have in various combinations with each other.
Indeed, even for chemicals that have a fairly long commercial history as plasticizers, flame retardants, pesticides, anti-stick coatings, or other uses, we typically still don’t have a good understanding, since their effects can gradually manifest over a period of decades or longer, and since there can be a complex interplay between a person’s genetics and the environment that would cause certain individuals to be especially susceptible even if others are not.
Because these chemicals are used in the manufacture of new furniture, canned goods, cookware, and other products; because these chemicals are present in the water, in the soil, and in the food we eat; because there is no good way to test for exposure or significantly reduce it, all children born recently were exposed to endocrine disruptors during fetal development. While these children’s brains and bodies were first forming, they were subjected to the influence of a variety of chemicals that mimic, suppress, or accentuate the effects of various hormones.
And there has been a steady upward trajectory in the prevalence of these chemicals in the environment over the past hundred years. Each generation has experienced fetal development inside wombs where these chemicals were more abundant than for the generation before.
This is not to blame mothers – these chemicals are so pervasive that it would be impossible for anyone to avoid them. And because so many hormones (and endocrine disruptors) initiate cascades of biological interactions that amplify their signals inside cells, even miniscule concentrations can have an effect on a person’s development.
Nor does this make contemporary humans any worse than our ancestors (in the way that old warriors in Homer’s Iliad griped that people used to be braver and stronger, and in the way that old men have presumably always griped in the past and always will in the future). There is always an interplay between a person’s genes and the environment. Our environment has been different, and so our biological enactment of our genes is different than it otherwise would have been, and, voila, this is who we are.
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A person’s perception of selfhood is rooted in the workings of the brain. And the brain is a physical thing. Thoughts result from a physical flow of signals through the physical maze of connections among our neurons’ axons and dendrites. And for contemporary people, this physical system – all those synaptic connections that allow for thoughts, feelings, and memories – has developed in conjunction with exposure to a wide variety of endocrine-disrupting chemicals.
As with any of our intentional medical decisions, we cannot know what the world would have been like otherwise. If a young person seeking gender-affirming care had been born in a world without those endocrine-disrupting chemicals, perhaps that person would not have experienced a mismatch between their brain and their body.
But it wouldn’t be the same person.
In Far From the Tree, Andrew Solomon writes:
A child may interpret even well-intentioned efforts to fix him as sinister. Jim Sinclair, an intersex autistic person, wrote “When parents say, ‘I wish my child did not have autism,’ what they’re really saying is, ‘I wish the autistic child I have did not exist, and I had a different (non-autistic) child instead.’
Read that again. This is what we hear when you mourn over our existence. This is what we hear when you pray for a cure. This is what we know, when you tell us of your fondest hopes and dreams for us: that your greatest wish is that one day we will cease to be, and strangers you can love will move in behind our faces.”
The world we’ve made – with a human population that harbors a wide variety of distinct developmental alleles (which means all our bodies will respond differently to the same stimuli), all of us awash in environmentally ubiquitous chemicals with potent, unstudied effects – has created children with these identities. It would be monstrously cruel to wish for their identities to go away, as though praying that pod people would arrive and replace the world’s actual children with more tractable simulacra. In any case, that wish would not be granted. This is who they are. And so we can choose now either to celebrate them, the fully human individuals with identities that perhaps we didn’t expect, or to try to stifle them, only to find ourselves living among people who hate us as they grow.
Frank Brown Cloud 