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Making sense of sex, gender, and trans issues

Adam and Eve expelled from Paradise. Alamy Stock photo.

Gender has become simultaneously one of the most talked about and most taboo subjects in our culture.

The rise of the transgender rights movement as a social and political force, together with an explosion in the number of young people identifying themselves as outside the “gender binary” has left many people and institutions struggling to make sense of where we are, and how we got here.

Charlie Camosy spoke with two leading academics about gender, sex, and what is happening across society and medical practice.

Abigail Favale, Ph.D., is a writer and professor in the McGrath Institute for Church Life at the University of Notre Dame.

A Catholic convert with an academic background in gender studies, Favale is a frequent writer and speaker on topics related to women and gender from a Catholic perspective. Her latest book is “The Genesis of Gender: A Christian Theory,” released in June.

John Grabowski, Ph.D. has taught moral theology at The Catholic University of America for the last 31 year, specializing in theological anthropology, virtue ethics, marriage, and sexuality.

His latest book, “Unravelling Gender: The Battle over Sexual Difference” was published in March.

In this first part of a two-part interview, Favale and Grabowski survey issues related to gender and sex, and ask how we arrived at a suddenly confusing and confused place.

Next week, they will discuss the pastoral challenges for the Church presented by those issues.

We’ll get to the important theoretical insights both of you have to offer in a moment, but first let’s start with the “what’s happening?” question with gender.

Grabowski:

Where to start?

Our current disassociation of gender from sex and the body has resulted in a proliferation of genders, with social media, celebrities, academics, and various legal bodies recognizing dozens — the U.N. is considering the adoption of treaties that would recognize over 100.

This set of ideas, that the Church calls “gender ideology,” has ripple effects across our society and culture. Medicine gets co-opted into attempting to use harsh chemical and surgical procedures to treat the pain of gender dysphoria that evidence suggests is primarily a psychological issue. The result is that people are left scarred both physically, for example, transitioning procedures destroy fertility in both men and women, and often psychologically, as the testimonies given by detransitioners make painfully clear.

Hand-in-hand with these developments are educational programs and initiatives (e.g., the gender unicorn used in some public schools or ‘drag queen storytime’ in public libraries) that seek to communicate to children the idea that gender is self-chosen and multiple rather than a stable binary.

Everyday language becomes fraught as people war over names and pronouns and can face social ostracism or even criminal penalties for willfully “misgendering” others. We’ve all seen the images of biological men who identify as transgender women crowding biological women off of winner’s platforms in women’s athletics.

Even more disturbing is the threat posed to women’s safety and personal space in public facilities such as restrooms, locker rooms, or prisons as they are forced to share these spaces with biological men who identify as transgender or predators posing as such.

Given all of this, it is clear that the repeated warnings sounded by the Church in recent decades are not mere hype or hyperbole.

Favale:

One important trend to track is the rapidly shifting demographics. Historically, trans-identification was a rare phenomenon, and it was largely middle-aged males who sought sex reassignment. In the past decade, this demographic has changed in two ways: now, far more females than males are seeking treatment at gender clinics, and the average age has plummeted to late adolescence.

Moreover, the number of people seeking treatment for gender dysphoria has sky-rocketed — especially among young people.

In the UK, for example, the number of young people seeking transition rose by almost 1,900% between 2010 and 2020. In the US, a 2022 study by the Williams Institute found that 43% of trans-identified people in the United States are below the age of 25, and trans-identification in this age group has doubled since their last report, issued in 2017. New Zealand, Finland, Canada, and The Netherlands have recorded similar increases in gender dysphoria and/or trans-identification among young people, so this is a consistent pattern across the West.

We are also seeing major shifts in therapeutic approaches, ones that are not based on high-quality scientific evidence.

There is a substantial amount of literature that’s been around awhile showing a high desistance rate for childhood-onset gender dysphoria. In other words, most kids (around 80%) who experience GD grow out of it by adulthood. Because of this, a “watchful waiting” and non-medicalizing approach was favored by most psychological and medical organizations, until recently.

To name just one example: in 2009 the Endocrine Society guidelines discouraged puberty suppression and cross-sex hormones for youth, citing the desistance rates. In 2017, they issued new guidelines that mandates “gender affirming” medical treatments.

What’s crucial to understand is that there was no high-quality, groundbreaking study that prompted this massive shift. The evidence supporting the medicalization of gender dysphoric young people is sparse and low-quality, and the long-term ramifications are not well understood.

Encouragingly, European countries are starting to recognize this.

In 2022, a Swedish government oversight agency conducted a systematic review of all available evidence and concluded that the supposed benefits of hormonal interventions for youth do not outweigh the known risks. In response, Sweden—which has been a progressive pioneer in gender affirmation—is now prioritizing psychotherapeutic interventions over hormones.

Similar course corrections are happening across Europe, in Finland, France, and the UK. The Swedish report also noted the growing number of detransitioners—people who start down the trans medical pathway and then change their minds, often left with irreparable physical damage.

This is another trend to watch, one that will hopefully prompt a wave of lawsuits in response to what is honestly a medical scandal.

Two of the most common reactions to people who articulate these concerns are that:

-”These are the fact-free overreactions of conservative fuddy-duddies who just need to get with the times.”

- “If you don’t give a full-throated response of gender affirming care you are ‘literally killing trans people.’”

How do you react to those ideas?

Favale: Well, to be totally fair, there have been some overreactions on the conservative side.

But not all critiques of the unquestioning affirmation model are coming from conservatives, and the best critiques are ones that are fact-based.

Sweden can hardly be dismissed as a fuddy-duddy, neocon country, and, as I noted above, their shift in protocol is entirely based on what they’re seeing on the ground and in the scientific literature.

This is a “canary in the coal mine” moment, and it is in America’s best interest to pay attention to what’s happening in Europe, because they are farther down this road than we are.

In addition, there are a number of trans-identifying adults, like Buck Angel and Scott Newgent, who are raising concerns about medicalizing children. There are also left-leaning critics, like Andrew Sullivan, speaking out.

In my experience, those who dismiss thoughtful critiques and questions are not familiar with the limited, flimsy evidence supporting these drastic and experimental treatments. Earlier I mentioned the high desistance rate of early-onset gender dysphoria; an additional point of information is that a number of these kids grow up to be gay. Many gay adults exhibit gender non-confirming behavior as children. So there is also growing concern that we are unnecessarily sterilizing and medicalizing gay young people.

It is well-established, and uncontroversial, that LGBT+ youth are at higher risk for mental illness comorbidities and suicidality. What is not well-established, however, is that the medical pathway is a panacea.

In fact, the only long-term, population-based study we have shows a 19-fold increase in suicidality after sex reassignment procedures—and that’s from Sweden, a society that has been very “gender affirming.”

So the “give-kids-hormones-or-they’ll-kill-themselves” narrative is not only unproven; it is dangerous. It has the potential to become a self-fulfilling prophecy and should not be thrown around casually. The bottom line is that we do not have good science in this area, yet we’ve been galloping ahead with risky and experimental therapies on children.

Girls as young as thirteen are having double mastectomies. Teenagers can walk into a Planned Parenthood clinic and start cross-sex hormones on an informed consent basis, without physician oversight.

It is prudent to raise questions, to urge caution. Unfortunately, opinions in this area seem much more shaped by polarized political tribalism than a dispassionate review of sound science.

Grabowski:

These are powerful, emotional arguments often deployed to silence critical questions or dissenting viewpoints.

However, they do not hold up to existing data or rational scrutiny.

There is significant evidence that chemical and surgical transitioning procedures are simply not good medicine, based on outcomes for patients who undergo them. We are just beginning to study and understand the long-term physiological and psychological effects of these procedures.

Use of puberty blockers has been linked to loss of bone density, stunted growth, infertility, and underdevelopment of genital tissue (Mayo Clinic, 2022; Carmichael et al., p. 40).  Even programs supportive of transitioning procedures acknowledge potentially troubling side-effects of cross-sex hormonal therapy ranging from decreased sexual function, pelvic pain, and infertility, to cardiovascular issues such as hypertension, and increased risk of heart attack and stroke.

The fact that some clinics and advocates are promoting puberty blockers and cross-sex hormones for children at earlier and earlier ages means that we are literally engaged in medical experimentation on children without a clear sense of the long-term risks and without their informed consent.

This is in spite of the fact that, as Abby mentions, the vast majority of gender discordant children (around 85% according to researchers) outgrow this condition with little or no intervention.

The existing scientific literature does not support the claim that transitioning procedures benefit patients.

In 2016, the Obama administration’s Centers for Medicare & Medicaid Services published a memo which concluded that, based on existing studies, there is no evidence of “clinically significant changes” after gender transitioning procedures.

In fact, like Abby, that document pointed to one of the largest and most scientifically robust studies to date, conducted by Karolinska Institute and Gothenburg University in Sweden, that found the rate of suicide among those who fully transitioned to be 19 times higher than the population as a whole.

This figure is adjusted to account for prior psychiatric illness and undertaken in an ostensibly “trans-friendly” culture. This wealth of scientific data can be personalized and given a human face and voice by listening to the testimonies of people who have detransitioned after realizing that their reconfigured appearance did not treat the real source of their psychological pain.

In the face of existing evidence, to call these procedures “trans-friendly care” seems an Orwellian inversion of language, obscuring a misuse of medicine.

People who identify as transgender deserve compassion and evidence-based medical care that helps them flourish physically and psychologically. Harsh chemical and surgical interventions do not provide those.

How did we get here? What historical, cultural, and philosophical forces brought us to this point?

Grabowski:

In the book I lay out something of the toxic brew of modern philosophies that help to generate this ideology, such as erasure of human nature and the family effected by existentialism, postmodernism, and Marxism.

These have had wide influence in our culture, where the family and personal identity have been fractured by the seismic shifts of the Industrial Revolution, the Sexual Revolution, and our ongoing Technology Revolution unfolding around us.

To highlight the impact of just a few of these cultural destabilizations, modern contraceptive technologies (themselves the jet fuel of the Sexual Revolution) remove the fertility at the heart of sexual difference from both marriage and the self, leaving the body without a telos.

On top of this, the digitalization of identity in our online worlds helps to underwrite the idea that the body is simply a screen on which to project an identity. If the sense of personal identity and the body don’t match, it can be overwritten with chemical and surgical transitioning.
All of this contributes to a uniquely 21st century iteration of the ancient heresy of Gnosticism. Gender ideology purports to offer a kind of this worldly salvation by overcoming the body and its “sex assigned at birth” in order to give expression a self-articulated gender.

Favale:

I think it’s important to resist a “just-so” story to explain a very complex phenomenon. That said, one prevailing factor has been a two-fold revolution in our cultural imagination and our material conditions: a conceptual revolution, and a contraceptual revolution. This is the story I trace in my book “The Genesis of Gender.”

First, the conceptual revolution: prior to the 1950s, “gender” was a linguistic term that psychologist John Money borrowed to explain his hypothesis about our identities as boys and girls being entirely socially constructed in the first years of life. He made a distinction between “gender,” which is a social construct, and “sex,” which is biological.

Second-wave feminists latched onto this sex/gender distinction, and in the 1970s this terminology became entrenched in the humanities and social sciences. In third-wave feminism, postmodern theorist Judith Butler posited that sex itself, not just gender, is a social construct—that all attempts to categorize or add meaning to basic biological features is a matter of social power rather than knowledge.

Through popular versions of Butler’s theories, the idea of the sex binary has been challenged, and now we’ve arrived at a strange reversal: “gender,” defined as one’s self of sense as woman/man/neither, is taken as innate and real, whereas “sex” is seen as a construct or fiction that can be changed.

This conceptual revolution unfolded in tandem with widespread acceptance and use of contraception. This contraceptual revolution greatly changed our sexual practices, norms, expectations—and most importantly, our shared understanding that “woman” and “man” are fundamentally defined by innate procreative potential. We’ve lost that instinctive awareness of maleness and femaleness as distinctive reproductive modes—instead, gender is about appearance, expression, and social roles. I argue in my work that this twofold revolution has brought us to our current moment.

Other important factors feeding the transgender phenomenon include the immersive and disembodied online milieu of Western youth culture, where identity can be easily altered, and also the pervasive influence of pornography on our conceptions of what it means to be man and woman, and what our sexed bodies mean.


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Can you say more about what you think is going on with young people and their peer groups?

Grabowski:

I don’t think there is a single factor that explains the whole of this phenomenon.  Part of it is likely the greater social acceptance of people who identify as LGBTQIA+ in our society, especially on the far side of the Obergefell and Bostock decisions which have seemingly added the force of law to the drift of our cultural trends of recent decades.

This is coupled with the dissociation of fertility from marriage and the body caused by the contraceptive turn of western culture and the digitalization of identity, has left younger people without a center of gravity for their identity. I also think that there may be some different forces at work when it comes to sexual attraction (i.e., people who describe themselves as LBG) versus identity (T+). The two are clearly related but distinct.

In regard particularly to those who see themselves as transgender, non-binary, gender fluid, or gender queer, there are additional factors in play. There does seem to be something like a social contagion effect of gender ideology, especially on young people who are struggling with identity for reasons other than gender incongruity.

We are seeing marked increases of this kind of identification among adolescents and young adults who had no previous signs of gender dysphoria as children.  Much of this seems to be the result of being exposed to gender ideology through peer groups and online sources.  The clinical name for this phenomenon is “rapid onset gender dysphoria” and we are just starting to understand it.

Favale:

Adolescence is a turbulent and difficult time for most people.

Your body is changing rapidly; you’re riding a hormonal tsunami; you’re developing a differentiated identity from your parents, often by testing and transgressing boundaries.

Adolescence is also a developmental stage when peer relationships become intensely important and highly influential. In addition, we’re also seeing a rising mental health crisis among young adults. I believe that our culture is now responding to a complex variety of adolescent angst and distress with a reductive, simplistic framework: “Your body is what’s wrong with you; that’s why you’re in pain, that’s why you feel different. If you fix your body, you will be happy.” That is an incredibly intoxicating narrative—but it is not a good one, and will ultimately cause more suffering.

In some ways this current phenomenon resembles other pathological social contagions: think of the rise of eating disorders in the late 80s-90s, the self-harming epidemic of the early 2000s. What’s new—and dangerous-–about this contagion is that it is being condoned and enabled by responsible adults and authority figures (parents, teachers, doctors, therapists).

Imagine a doctor prescribing diet pills or surgery to treat anorexia. Imagine a therapist providing tips and strategies on cutting, without ever trying to explore what might be at the root of the distress. This gender affirmation framework has rebranded self-harm as self-care.

I also think that there is an unconscious protest happening, a rebellion against harmful scripts about what it means to be a man, what it means to be a woman.

Increasingly, these scripts are being shaped by the pornified hypersexualization of our culture. Young people are exposed to porn at young ages. Think about what that is teaching them. It’s no wonder so many young women want to opt out of womanhood, if that’s what it looks like — to be dominated, exploited, objectified.

Conversely, I hear in some first-person accounts of male detransitioners a parallel flight from manhood. Who wants to grow up to be a man, if masculinity is toxic and predatory?

We are in desperate need of positive accounts of what it looks like to flourish as a man or as a woman, accounts that resist stereotypes and show the manifold ways to live out one’s sex meaningfully in the world.

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