← Return to search results
Back to Prindle Institute

gender identity

Posted on

“Born This Way”: Strategies for Gay and Fat Acceptance

Birds-eye view of a crowd of people. Some people are in focus and others are blurred.

In light of the recent discussion around Florida’s “Don’t Say Gay” bill, you might have come across the argument that lesbian, bi/pansexual, and gay people did not choose their sexual orientation and cannot alter it and that’s what makes homophobia wrong. Call this the “born this way” argument. Interestingly, a similar response is often given to the question: What makes anti-fat bias wrong? The argument states that people cannot usually exert control over the size of their body, and diets don’t usually work. So, we shouldn’t blame them for or expect them to change something they can’t control.

Are these good answers? While both “born this way” style arguments have some truth to them, I don’t think that either gives us the best strategy for responding to these kinds of questions. Politically, they can only get us so far.

First, there is still some control that individuals can exercise in both cases. Gay people could choose to be celibate or live in a heterosexual marriage, though, of course, those actions are likely to be highly damaging to their happiness. Fat people could choose to continually stay on some diet and access medical interventions, even though they will likely gain the weight back and suffer in the meantime.

This limited control gives the homophobe/anti-fat person a foot in the door. They might argue that gay people should be celibate or force themselves to live in heterosexual relationships and that we can blame them if they fail to do so. Or that fat people should consistently diet and try to change their bodies through any means necessary. If they fail to do so, the anti-fat person can claim that they are blameworthy for not caring about their health.

It should be obvious why these are undesirable outcomes: neither rationale allows the gay person or the fat person to accept and love these core aspects of themselves. Each still effectively marginalizes gay people and fat people. These strategies simply shift the target of blame from the desires/physical tendencies themselves to the person’s response to those desires/physical tendencies. They require that you reject who you love/your own body.

Second, assume that it would be possible to argue that people can’t control their sexuality or weight at all, even to abstain from relationships or go on diets. The “born this way” style of argument blocks blame, but it doesn’t block the general attitudes that it is worse to be gay/fat and that gay/fat people cannot live full and meaningful lives.

Even if being gay or being fat are or have been associated with higher health risks (see, for instance, the recent spate of articles on COVID and obesity), that fact alone is insufficient to see these social identities as somehow inferior. For instance, failing to use sunscreen can contribute to poor health and is under personal control, and yet no one considers that behavior grounds for discrimination. Additionally, health risks such as AIDS or diabetes are not fully explainable by individual behaviors — they are also informed by public health responses, or a lack thereof, as well as by other material and social consequences of discrimination. Creating stigma does not help public health outcomes and it actively harms members of marginalized groups.

These negative associations with fat and gay people fail to take into account the kind of joy that fat and gay people experience when they accept themselves and can live full lives. See, for instance, the deep love that queer people have for each other and the loving families that they create, or the kind of joy felt in appreciating one’s fat body and enjoying living in it. Representation of fat and gay people being happy and living good lives is more likely to lead to health and happiness than campaigns to increase stigma.

Third, the “born this way” style argument, while it can be used to block some of the worst oppressive legislation and attitudes, is not the most helpful for a campaign of liberation. But what would an alternative look like? Probably an argument that shows that homophobic/anti-fat attitudes are wrong, because being gay/fat is a legitimate way to be in the world, and gay/fat people deserve equal respect and rights. In such a world in which gay/fat rights are enshrined by law and respected, gay/fat people can flourish.

With this answer, we haven’t simply blocked the ability to blame gay/fat people, we’ve blocked the judgment that there’s something morally bad or blameworthy about being gay/fat in the first instance. We’ve also avoided thorny issues surrounding what control any given individual has over their situation, and we’ve re-centered the need for positive changes to make life better for gay/fat people, to make them equal citizens, and to encourage their friends and family members to love and accept them. Of course, this project will require that we deal with the specific kinds of oppression that differently legible fat people and different sub-categories of LGBTQ+ people face, as well as how these identities can intersect with each other and with other marginalized identities.

This doesn’t mean that we should totally jettison “born this way” style arguments, but it does mean that we need to re-emphasize building and living into the kind of world we want to see. “Born this way” style arguments might be a part of that strategy, but they can’t be the core of it.

Posted on

Whose Rights Matter for Gender-Affirming Care?

photograph of youth holding small Trans Support Flag at rally

Should medical decisions involving children be up to children, parents, physicians, the state, or some combination thereof? This question has been at the core of recent issues including vaccine mandates, but it is also central to a new slate of bills targeting gender-affirming care for trans youth, which are usually supported by appeals to children’s rights.

For example, the Idaho House recently passed a bill that makes it a felony, punishable by life in prison, to provide gender-affirming medical care to trans youth, to provide permission for a minor to receive that care, or to permit a minor to travel out of state to receive care. The bill has since been blocked in the Idaho Senate, due to concerns about parental rights. Similar laws are being proposed in Tennessee, Alabama, and Iowa.

What is interesting about these bills (as well as Florida’s “Parental Rights in Education” bill) is that they are contested on the basis of a conflict between children’s rights and parents’ rights. In the case of gender-affirming medical care, whose rights matter more?

It seems that the proponents of these bills are right to say that it is the children’s rights that are primarily at stake in these decisions — not the parents’. They are wrong, however, to say that children’s rights support this kind of legislation.

Except for therapy, gender-affirming medical care begins around puberty, when children have basic reasoning and decision-making capacities and start to develop as autonomous agents. These capacities may not yet be fully developed (and young adults may not yet be socially and legally independent), but this fledgling autonomy is sufficiently developed to warrant and even require that these children are part of the medical decision-making process. However, before minimal autonomy is reached, parents and physicians should be very careful about making medical interventions to alter a child’s sexed presentation, especially given the long history of medical abuse of intersex people.

Apart from considerations about autonomy and decision-making ability, the other primary consideration is whether these interventions will help or harm the children who undergo them. Both concerns target children’s rights.

The two questions we should ask are thus: Can children who have reached puberty consent to medical intervention? And do these interventions harm or help children? For those proposing these laws, the answers are that the children cannot give informed consent and that these interventions are, on balance, harmful. But are these assertions true?

The answer to the first question is supported by ideas that children cannot yet know their gender identity and how they would like to present, or that they will transition just because it is cool, or that they will choose transition as an easy out from facing misogyny or mental health problems.

If children cannot yet know their gender identity, then it seems that puberty blockers should be recommended for even more children, as it would allow them to delay the changes their bodies undergo so that they can make informed decisions about how they would like their bodies to develop at a later date.

It also seems unlikely that being trans is cool enough to persuade children to transition on that basis alone. In 2019, 2% of high school students identified as transgender. That is hardly as popular as wearing crocs, and it comes with significant social costs.

The last rationale is usually cited in the case of trans men. Misogyny is an issue that many people assigned female at birth have wrestled with and that has informed both cis and trans folks’ gender identities, but transition is not an escape from oppression — it trades one kind of oppression for another. One might also worry that there’s a subtle misogyny in implying that people assigned female at birth are less capable of making competent decisions about their gender identity than those assigned male at birth.

Even if each of these worries were true, they would tell in favor of more care rather than less. Instead of cutting off options to children and leaving them without a good understanding of gender identity or the medical options for transition, we should be providing children with more options and with better counseling to enable effective joint decision-making. This provides children with greater autonomy than if they are left without any choice, and it allows them to explore for themselves where their feelings are coming from and what they indicate.

It is important to note that not all transgender or gender non-conforming children will choose to undergo medical procedures or the same set of medical procedures. There is a critique to be made here that our current system of medical care often prioritizes certain narratives of medical transition over others and tends to overlook the needs of those who don’t fit into these neat categories, especially non-binary people. But again, this tells in favor not of removing medical care but of improving it. We should be striving to provide adequate information to children in the decision-making process and, as the therapy begins, encourage re-evaluation of medical care and adjust that care in response to the child’s wishes.

Turn now to the second question: Even if children can give at least partial consent, is the harm done by gender-affirming care great enough to override what autonomy they have? To determine the answer to this question, we need to separate out different kinds of gender-affirming care. Though gender-affirming care encompasses a wide range of options, let’s simplify those options into the following categories: talk therapy, puberty blockers, hormonal therapy, and surgical intervention.

While talk therapy and puberty blockers present some risks, the main worries that proponents of these bills cite primarily target hormonal therapy and surgical intervention. The two major harms presented in support of this legislation are a loss of reproductive ability and the difficulties faced by retransitioners (people who transition back to their gender assigned at birth or who transition to a different gender, e.g., trans man to non-binary person). These are non-negligible considerations. But do they capture everything morally salient for decision-making?

There are other harms we should take into account that would result if these bills were to pass: an inability to medically address gender dysphoria (a psychological incongruity between one’s gender identity and presentation, which can result in psychological distress), the disruption of the patient/doctor relationship, the message that these bills send that trans youth are not seen or appreciated, the tendency of these bills to exaggerate inter-family conflicts when one parent supports a child’s gender transition and the other does not, the tendency of these laws to increase the risk that trans youth commit suicide, and the difficult to alter changes that happen after a child’s body naturally starts producing estrogen and testosterone at puberty, in the absence of puberty-blockers.

The question about access to gender-affirming care isn’t simply one about avoiding these harms — it’s also about promoting positive experiences like gender euphoria (joy felt when one’s gender lines up with one’s presentation and social relations with others). But do the worries about loss of reproductive ability and retransition override these other considerations?

With regard to retransition, several studies have indicated that only around 1% of patients regret their transition. The people who regret their transitions matter, and medical care should be tailored to prevent such regrets and address them when they arise. But the existence of very few who regret medical transition should not be used to deny gender-affirming care to others, especially when that gender-affirming care can be life-saving.

Regarding reproductive worries, many trans folks would like to have children of their own. While we are not yet to the point where trans women can bear children or trans men can produce sperm, trans women and men can rely on technologies that freeze their sperm or eggs and that allow them to produce a biologically related child in the future. Unlike surgery, hormone therapy does not necessarily make the patient infertile, though counseling is recommended to ensure that patients understand the reproductive ramifications of certain medical interventions. And the one surgery that is currently accepted for under 18 individuals is “top surgery” or double mastectomy.

These reproductive ramifications should be fully transparent to teens who are deciding what therapies to access, but these considerations alone do not seem to immediately rule out medical transition, given that they may be outweighed by a number of benefits. In addition, reproductive capacity will mean different things for different trans people, as, for example, some trans men may wish to avoid pregnancy at all for reasons of gender dysphoria.

We also tend to think that adults should have reproductive freedom in choosing whether to have a tubal ligation or vasectomy, and the teens who would have access to hormonal therapy would be much closer to adulthood and full autonomy. Given their greater autonomy, it is less worrisome to allow them to make a joint decision with potentially negative long-term ramifications.

On the whole, gender-affirming care appears to be more helpful than harmful and certainly not harmful enough to warrant overriding the autonomy of older children and young adults. Current practices of gender-affirming care rightly provide less risky treatment to younger children and more risky treatment to older teens, which mirrors the growth of autonomy and decision making through young adulthood.

Bills that would deny gender-affirming care are insidious because they take away the rights of trans youth while claiming to protect those same rights. It turns out that if we want to protect children’s rights, we need to fight legislation that would deny access to gender-affirming care.

Posted on

Is Biden Trapped by Identity Politics?

photograph of Biden at rally pointing to the crowd

As anticipation continues to build over Joe Biden’s choice of running mate, he’s announced  that his preference is for a candidate of a different race and gender than himself and followed this up with a commitment to selecting a candidate of a different gender. This rankles many people, even some with otherwise liberal leanings. The thought, it seems to them, is that candidates for office should be selected entirely on the basis of their qualifications, without consideration of their sex or race. To think otherwise, now, has come to be pejoratively called “identity politics”, and as more Democrats push for Biden to choose a Black woman, right-wing voices delight in the insistence that Biden is being held hostage by identity politics. What’s so bad about that?

Identity politics is often treated as a term of abuse. This is not surprising, as the concept now so often stands for politicians using their racial or gender identity — or proximity to such — as a means to achieve political aims such as winning an election or silencing critics. New York Mayor Bill de Blasio, for example, has seemingly attempted to counter the growing number of criticisms from African-American former allies by increasing public appearances with his African-American wife, Chirlane McCray.

Such uses of identity politics appear cynically calculated to influence voters’ decisions not through sound argument or policy, but by appealing to a desire to support one’s group. In the worst-case scenario, identity politics in this sense is meant to deceive voters: it tells them that a candidate is one of them, or on their side, while endorsing policies that harm them. Identity politics can, of course, be abused in this way, in what Olúfẹmi O. Táíwò has called “elite capture”: the process by which a movement is exploited by elites to serve their own purposes rather than those of the people it is supposed to help. But abuse of this kind is not unique to identity politics, and so not a reason to dismiss it as harmful in itself.

It would be objectionable if Biden or those pressuring him were using identity politics in order to manipulate voters into acting in ways that harm them while helping Biden or his party. But for that to be the case, it would have to be true that he is actively pushing for policies that would harm the voters such a stratagem is designed to win over, and it’s unclear that he is — at least compared to his opponent. Moreover, for him to be using identity politics in this way, it would need to be the case that distracting voters from their real interests were his main reason for leaning toward a Black woman as a running mate. But there is no evidence of this, and it seems unlikely considering the chorus of his supporters pushing him to make this choice. It’s true, of course, that Biden is trying to win the election, and any running mate he chooses will be someone calculated to help him do that. But presumably he does a lot of things with that aim, most of them unobjectionable. If his purported reliance on identity politics is a problem, then, there must be a further reason.

One common objection to identity politics holds that voters have “been presented with a narrative and arguments convincing them to rely on identity politics, or in other words, shallow stereotypes,” as Tammy Bruce puts it. On this uncharitable view of identity politics, it functions primarily by reducing people to representatives of particular identities rather than recognizing them as individuals. Perhaps, then, the critics mean that in having to choose a Black woman candidate, Biden is ensuring that whoever he eventually chooses is not chosen for her qualifications, but for her gender and race alone. This is a popular take on identity politics, but it comes with its own set of problems.

First, to think that the pressure on Biden forces him to choose not a person but a stereotype seems to itself reduce Black women to stereotypes, since simply committing to a Black woman candidate does not imply either that anyone who meets that description is equally qualified nor that everyone who meets that description is qualified. The thought, instead, could be that although a number of Black women are perfectly qualified to be vice president, no one from that demographic has ever been chosen for the role due to a social depreciation of their race and sex. Seen in this light, a commitment to choosing a Black woman need not appear as a commitment to choosing a stereotype, but to choosing from a typically overlooked pool of excellent candidates.

Second, there is an underlying assumption that one’s sex or race is irrelevant to one’s qualification for a job. But clearly this is not always the case. It makes good sense, for example, to choose a Black spokesperson for the NAACP or a woman to consult women on reproductive issues. In these cases, a candidate’s race or sex is a qualification for the position, though it is not the only qualification and may not even be a necessary one. If, for example, a reproductive counselor is needed but no women with the requisite training can be found, it would make sense to choose a man. Still, to strongly prefer a woman for that position is not in itself problematic. There is no reason that the same might not be true of a candidate for vice president, especially if we consider that what qualifies one for that role is not some fixed set of laws, but an interplay of the historical and cultural context with the presidential candidate’s and their party’s strategy and priorities.

But there is an even more widespread, and perhaps slightly more highbrow criticism of identity politics, leveled by pundits from the liberal middle to the far right of the spectrum, such as Mark Lilla, Francis Fukuyama, Jonah Goldberg, and the Heritage Foundation. The spirit of this criticism isn’t so much that identity politics encourages us to see each other — and ourselves — as stereotypes. Instead, while such critics sometimes express sympathy for identity politics, they argue that by focusing on group identities it undermines the communal ties that bind us together. On this view, identity politics weakens our shared values by encouraging us to view ourselves primarily as members of sub-national groups and to focus on the interests of our group rather than those of the country. From this perspective, in expressing a preference for a running mate of a particular race and sex, Biden is sending a signal to some social groups that he is on their side but simultaneously telling other groups that he is not on theirs, and that he represents a fundamentally different culture from their own: one that prizes diversity over their interests.

But the view of identity politics as essentially divisive only works if we assume the divisions aren’t there to start with, or that they are minor enough that drawing attention to them causes more harm than good. If the divisions are already there, however, the options are to ignore them or to work to repair them, which cannot be done without recognizing that they exist. Now suppose that an electorate overwhelmingly votes for white men, regardless of the qualifications of others in the running. We might think that such an electorate is flawed. Waiting for the political landscape to improve on its own might work, but it also might not, since the electorate reproduces its biases with every election, choosing the person who “looks right” for the job, and thereby ensuring that that’s the kind of person who looks right for the job. In the meantime, an entire field of highly qualified candidates is left out. Another alternative, then, is to change the landscape by providing extra support for the candidates who don’t fit that type.

Identity politics — or at least the term itself — began life with the statement composed by the Combahee River Collective in 1977. The Black lesbian activists who comprised the collective did not take the concept to mean that they should get special treatment simply because they were Black, women, and lesbians. Instead, the thought was that insofar as society is structured in a way that does not treat all equally, they have a better insight into the inequalities that affect them than Black men, or straight women, might have. But the goal is not to splinter into ever-smaller groups, each demanding different treatment. The goal, rather, is for each group to lay out the ways in which it is not treated equally, so that different groups can come together in solidarity to help right each other’s injustices. Identity politics is the means; solidarity is the end. Elizabeth Drew asks, “But why does a woman necessarily merit a head start on the next presidential nomination?” The answer, perhaps, is that it’s time that women — and especially Black women — have the platform from which to present their own solutions to injustice.

Posted on

Examining Medical Intervention and Gender Confirmation

Photograph of an exam room in a doctor's office

There has never been a time when a society was made up of people that “naturally” fit into any sort of gender binary. People have lived lives across a spectrum of societally constructed gender roles since humans lived in cultures that developed gender roles in the first place. In contemporary contexts, we have the ability to support people living according to their identities when they differ from the gender assigned at birth in new ways thanks to developments in medicine. However, there is debate about how to understand this support in terms of the role of medical intervention.

If we define appropriate medical intervention in terms of “treatment”, we are understanding medicine as fixing something that is wrong, balancing potential risk of further harm against present suffering. The appropriate role of medicine is a contentious issue, especially in societies where the costs of interventions are prohibitive when deemed superfluous in any way. A central distinction in this discussion is between treatment and enhancement. Treatment covers medical interventions aimed at making patients healthy and well, and enhancement refers to medical intervention that does not address deviation from health but rather makes the patient better than well. Insurance companies can try to rely on this distinction to determine what interventions to cover the cost of and to what extent, for treatments may delineate interventions that are “medically necessary” while enhancements typically do not.  

Cosmetic surgeries are thus deemed enhancements because there is nothing medically wrong with the patient and the intervention is taking them, arguably, to a state of “better than well”. The distinction isn’t a perfect one, as there are medical interventions that are intuitively appropriate but that don’t presume illness or deviation from health – such as contraception and obstetrics.

For individuals seeking medical intervention to alter their gender presentation, this distinction is important. Typically, in order to consider intervention necessary, a suitable illness or deviation from health needs to be identified and an improvement that will result from the intervention. For instance, if you have a herniated disc and seek surgery to improve movement and alleviate pain, this fits the common conception of medically justified intervention. Elective surgeries, such as cosmetic rhinoplasty, are not seen as having a medical justification and are pursued based on preference or whim, say, and insurance companies do not cover such procedures on these grounds.

While the World Professional Association for Transgender Health (WPATH) only requires informed consent before medical support for gender affirmation procedures including hormone therapies and surgeries, the reality in the US is more restrictive. For instance, in April of 2018, the AMA Journal of Ethics argued against a prohibition in place excluding medically necessary gender affirming surgeries for veterans.

In order to qualify for surgery, Aetna requires letters from medical professionals, documentation of persistent gender dysphoria, and, depending on the treatment, the individual must have lived as their identified gender for a year with hormone therapy. In order to obtain letters from medical professionals, individuals must convince these professionals of the genuineness of their identity.[1] This has historically lead to “gate-keeping” and pressure on individuals seeking gender confirmation procedures to fit a particular narrative of gender identity and expression that medical professionals will grant warrants medical intervention: a narrative that moves medical intervention into a category with broken limbs and cancer rather than with elective interventions like liposuction and cosmetic adjustments.

Whether you are cisgender, non-binary, or trans*, consider your experience in elementary school: there is no way all of your traits, preferences, characteristics, behaviors, etc. fit neatly into a category that society has determined is gendered according to whatever gender you were assigned at birth. This is relevant, because for individuals who identify as transgender, or individuals who seek to identify as a gender that is different from that assigned at birth (be they genderqueer, non-binary, etc.), there is frequently a heavy narrative burden placed on them to justify this identity in order to receive treatment.

There is not a univocal experience for individuals who identify differently from the gender they were assigned at birth. This makes creating objective or universal standards for when gender confirmation procedures are “medically necessary” or “treatment v enhancement/elective” particularly difficult. As Andrea Long Chu articulates for The New York Times, the experience of dysphoria and the stakes of getting confirmation surgery are complicated in a way that perhaps bears more nuanced deliberation. In, “My New Vagina Won’t Make Me Happy…and it Shouldn’t Have To”, she puts pressure on the utility and justice of applying the standard cost/benefit analysis to medical intervention for gender dysphoria. As she points out, when physicians can rule out intervention considering their assessment of the risks of the procedure and the possibility that the individual will continue to experience pain and discomfort of dysphoria, it can become more difficult to justify medical intervention.  

The appropriate role of medical intervention is a politicized issue due both to the power of health insurance companies who have strong incentive to withhold coverage for intervention as well as the (too often radically) slow advance of our cultural understanding of the lived reality of members of society.

 

[[1]]  According to the AMSA, “There is much controversy surrounding transgender identity and the field of mental health. At the moment, transgender people often receive medical care under the diagnosis of ‘Gender Dysphoria’ found in the Diagnostic and Statistical Manual of Mental Disorders V, while in the past being diagnosed with ‘Gender Identity Disorder,’ now considered an outdated and incorrect term. Many people believe that transgender identity is NOT a mental disorder and should be a medical, rather than psychiatric, diagnosis. Some physicians use the diagnosis, ‘endocrine disorder otherwise unspecified,’ to avoid using a psychiatric diagnosis altogether.”