The Department of Inhumanity and Ideological Services

A memo was recently leaked from the Department of Health and Human Services. In it, the HHS defines sex as a binary determined by chromosomes (presumed to come in only two forms, XX or XY), and states that sex cannot be changed.

The memo has caused outrage, because its goal is to define gender transition out of existence. Its aim is to discriminate against trans people, declaring them to be deluded or deceptive, their lived genders irrelevant. In so doing, it ignores the conclusions of every mainstream medical and psychological association, which is a bizarre position for a department supposedly aimed at recognizing and supporting medical treatment paradigms to take. Unrecognized as yet is how this proposed policy would also work to shatter the lives of intersex people. As is so often the case, intersex people's lives and needs go unrecognized, so in this post I will try counter that.

First, we need to understand where this memo is coming from. The Director of the HHS Office of Civil Rights is currently Roger Severino. He used to work for the Heritage Foundation. He has no special knowledge of medical issues--he was hired by the Trump administration to please conservative Christian groups. He is an advocate of conversion therapy for LGBT people. He says being LGBT is "against biology." He believes in a radical conservative Christian ideology that states that patriarchy, heterosexuality, and cisgenderism are compelled by the Bible and nature, and that Christians are forbidden from tolerating gender egalitarianism or LGBT people. Unsurprisingly if very sadly, rather than doing his job as Director of the HHS Office of Civil Rights, which is to see that the medical needs of all people, as understood by the medical profession, are met, he is seeking to impose his ideology. Rather than fostering humanity and human services, he seeks to advance discrimination and a radically conservative ideology of sex and gender.

What's especially insidious is that this extremist political position is not being proposed for debate--not that human rights recognized by the UN and international community should be debatable. But by inserting its bigoted assertion--that sex is a binary determined by chromosomes that cannot be challenged or changed--into the HHS definition, radical conservative Christian ideology is disguised as scientific fact. This is a common tactic today in that segment of the far American right that seeks to dismiss scientific consensus. They find some person of supposed authority who will ignore what the vast majority of experts affirm to be true, and present the assertions of that person as "disproving" the voice of the vast majority--this is very evident when we look at their approach to defying the national and international consensus of climate scientists.

In this case, the action is even more radical. The idea is to have the institution created to protect people's rights to health simply declare gender transition invalid. Many Americans will be unaware of the politicization of what is supposed to be a scientific body. They will believe that the medical profession actually opposes recognition of trans people's identities based on scientific study. Therefore, they will believe they need feel no guilt when gender policing people, and discriminating against those whose appearance strikes them as insufficiently conforming to binary sex and gender expectations.

As an intersex person who has gender transitioned, I can attest that if this proposed policy becomes law, trans people--some of whom are intersex--will suffer greatly. This is the aim of the radical conservative Christians who have been given an outsized voice by the Trump Administration. I have lived a decade in my identified gender as a man. My wife, an intersex woman, started her gender transition over two decades ago, as soon as she turned 18 and could control her own medical destiny. These decades of our lives, our gender identities, and the understandings of our friends, families and colleagues would all be declared lies. Humiliating us by misgendering us would be proclaimed "healthy." Discrimination against us would be declared justified.

But many more people than just trans people would suffer. The majority of intersex people in the U.S. today do not gender transition. But all of us have been fighting for social acceptance, for an end to infant genital surgeries that rob us of the capacity for sexual sensation, and against the stigmatizing and concealment of physical sex variance. Our battle as intersex people has been for recognition of the sex spectrum, and for respecting our physical sex diversity.

Think what will happen to us now. Consider, for example, those of us who have complete androgen insensitivity syndrome, born with female-typical genitalia but XY chromosomes. Virtually all people with XY, CAIS are assigned female at birth and are raised as girls--but suddenly, they'd be declared men. This would disrupt not only their lives, but those of their parents, their spouses, their neighbors and friends. Or consider all the children born with intermediate genitalia. Doctors have forced surgeries onto so many, basing their decision on factors like gonads, or surgical convenience. Suddenly, many intersex people would find that the surgeries forced on them took away the parts of their bodies that the new HHS policy declares to be the ones that should have been kept under the new chromosomal standard. This will compound their trauma--and perhaps lead to a further round of unwanted surgical interventions.

For those of us intersex people whose chromosomes are XX or XY, this new policy would counter all of our efforts to push back against forcing sex reassignment surgeries onto us, mutilating our genitals. Instead, the policy would declare that these are not sex reassignment surgeries at all, because our penises are "false penises," our vaginae "fake." And for those of us who have one of the many other sex genotypes this policy fails to recognize--XXY, XYY, Xo, XX/XY, etc.--ironically, even if our bodies have appeared typical enough that we've escaped surgical mutilation or social stigma, suddenly, we become the "true intersex," our lived genders falsified, leading to confusion, discrimination and shame.

The intersex community's central goal for many years has been to put an end to nonconsensual infant genital reconstructions. And our best bet for seeing this happen has been to educate parents--to let them know that intersex status is fairly common and in no way a tragedy, so long as children have the respect and support of their communities. This HHS policy would undo our good work in parental education by declaring to parents that what we've been telling them is false. The HHS policy says that only binary sex can be recognized, physical sex variance is intolerable, and "corrective" surgery a necessity. This is a tragedy for our community.

The deepest irony here is that we as intersex people have bodies that prove that this proposed HHS policy is, to be blunt, complete BS. Sex is not a binary--empirically speaking, it is a spectrum. If you look at world societies over history, most have recognized more than two sexes. This is not because until the modern West appeared with its binary gender ideology, everyone was deluded--it's because there have always been intersex people. The capacity to attempt to erase us surgically is only a century old, and other societies dealt with us very differently--by recognizing and accommodating us. Sadly, binary gender ideology is so passionately adhered to in our society that most Americans are unaware of both this world history of diversity in social sex categories, and of the prevalence of intersex people today.

And what this proposed inhuman policy does is attempt to codify that ignorance, declaring binary sex ideology the law of the land. The aim is to trample upon trans people--but the victims will include intersex folks, and empirical truth.

Trans-Exclusionary Radical Feminists and Intersex Experience

Recently I spent several days in a public internet group for "gender critical" people, after a few intersex friends voiced some positive things about this line of thinking.  Feminists who call themselves "gender critical" are a controversial bunch, but their critique of the term "cis gender" had caught the interest of some intersex people I respect.  The term "cis gender" is an awkward one to use in the context of intersex people, which was the subject of my last blog post.  So I wanted to approach this branch of feminism with an open mind, and see if there was theorizing or political advocacy I could use in my intersex work.  The group I joined promised respectful listening to people of varying beliefs, and banned personal attacks, so I had high hopes.

My hopes, I'm afraid, were naive.  The group turned out to be completely dominated by "TERFs," trans-exclusionary radical feminists, and when it came to intersex topics, not people I would consider good allies in the least.  So, since I know there are other intersex advocates who've presented "gender critical" politics in a positive light, I wanted to write a post about why I consider this a bad idea.

First, since I suspect that a good number of readers may be unfamiliar with the terms "gender critical" and "TERF," I will present an overview of the beliefs involved, in the form of a handy numbered-list primer.

A TERF Primer

1.  Calling themselves "radfems" or "gender-critical feminists," and named TERFs by radical-feminist-identified people who are not transphobic, these are cis women who oppose the inclusion of trans women in feminist organizations, women's spaces, and female facilities.  TERFs do not describe themselves as cis women, however, but as women-born-women, natal women, or (unmodified) women.  They assert that the terms "TERF" and "cis" are slurs.  Generally they just refer to one another in discussions as "feminists" and as "women," as if anyone who is a feminist would agree with all that they say, and as if their female status should go unmarked, as the normative or "real" female status.

2.  Trans-exclusionary radical feminists believe that sex is a natural binary, innate and immutable: men have penises, women have vaginas and uteri.  They note that gender is a relationship of power, in which men seek to control women's uteri, reproductive capacities and lives.  The ultimate expression of this patriarchy is the use of the penis to rape.  As a result, "gender critical feminists" make the strong claim that anyone who denies that sex is a binary and that genitals determine gender is ignoring the terrorizing of (natal/cis) women by rapists.

3.  TERFs argue that sex cannot be changed: trans women are really and eternally men, and trans men are really and eternally women.  Identifying with a gender that doesn't match one's genitals is a delusion or mental illness.  The phrase "gender critical" denotes being critical of (or more bluntly, rejecting) the concept of gender identity--most especially the fundamental precept of trans gender advocacy, which is that when gender identity and legal sex conflict, this provides pragmatic and ethical justification for a change of legal sex.

4.  TERFs deny that they are transphobic, and say they have compassion for men under the delusion that they are women, which they present as equivalent to believing one is really a horse or a space alien.  Dysphoria with one's body, they point out, is not a special characteristic of trans people, but a near-universal, and the solution is to accept one's body.  Accepting one's body means accepting that one cannot call oneself a woman while having a penis.  (Nor can sex be altered through genital reconstructive surgery , which is a radical mutilation to no purpose, as genes can't be changed and binary sex is essential.  But in most of the discussion threads I read, it was assumed that trans women all have penises, making them dangerous, as penises are rape weapons.  In fact, I've never read the word "penis" so often outside of a urology blog.)

5.  TERFs are not just binary sex essentialists, they also have a theory of gender socialization.  Their vision of gender socialization is bleak: boys are socialized to dominate, control, and rape women; girls are socialized to submit to this and embrace their oppressors and call this "femininity."  Clearly this is bad, and feminism is a movement of (natal/cis) women that teaches women to recognize and resist this programming.  Men, however, are presented as inevitably and eternally shaped by their socialization into patriarchy, as it advantages them.  Trans women are men, and while they may claim they do not enjoy being treated as men, this just illustrates their blindness to their own privilege.  Trans women are inevitably socialized to try to control "natal" women, as evidenced by their belief they should be able to force cis women into supporting their gender delusion and treating them as sisters.

6.  Thus, this conclusion about trans people: trans women are confused men, fetishists of the feminine, who are prompted by their male socialization to seek to control women--in this case, due to their delusion that they are women, to control feminism and women-born-women's spaces.  Trans men are less of a problem, since they pose no threat to anyone, lacking both penises and socialization into the role of the oppressor.  Trans men are just sad: women who don't understand that it's ok to be a butch woman or a lesbian, victims of Stockholm syndrome identifying with their oppressor.  Women who are deluded into thinking they are men should be pitied and exhorted to return to the fold.  But men who delude themselves that they are women are a serious problem.  They must be stopped: with exclusionary policies, taking back feminism from a trans-obsessed trend; by fighting antidiscrimination clauses that would let trans women and girls use women's bathrooms; through telling the world that supporting trans children in their identities is child abuse.

7.  Feminists who are trans allies and transfeminists counter each of these points.  They state that sex is not a natural binary, but naturally a spectrum (i.e., intersexuality happens).  They point out that many cis women lack uteri, yet are still considered women by everyone, even TERFs.  They note that gender socialization is complex and variable, that it is shaped by the gender with which one identifies, and that acknowledging both these facts is in no way a denial of the reality of patriarchy.  They assert that it is important, however, to acknowledge the intersectional nature of marginalization and privilege, and speak not just of patriarchy but of kyriarchy, taking into account race, age, sexual orientation, (dis)ability, and other dimensions along which power is distributed.  And one of these dimensions is the axis of cis privilege and trans marginalization.  Trans women--particularly those who are poor, of color, and/or have a disability--suffer huge levels of social stigma, violence, employment discrimination, etc.  Cis women need to acknowledge that while they are marginalized as women, they are privileged as cis people.

8.  TERFs respond to trans allies with anger.  They say trans allies are dupes, following a trend that counters basic logic, biology, nature, and the English language when they accept the idea that a person with a penis can be called female.  (Quoting the dictionary is popular to "prove" that genitals determine gender.)  They discount all the statistics about violence against trans women (and to a lesser extent trans men) as manufactured and overstated.  They assert that a woman can never oppress a man, and trans women actually being men, "natal" women cannot oppress them.  The TERFs repudiate being termed cis gender, equating the term "cis" with gender-conforming and unenlightened femininity, and regularly linking it to the violent phrase "die cis scum," which they assert is the core sentiment of men who think they are women, as if trans women's goal is to kill off all cis feminists so that trans women can have every feminist organization that exists all to themselves.  Finally, they equate acknowledging cis privilege with asserting a belief that women are not oppressed.

Intersex People and "Gender Critical" Politics

It's clear that I view TERFs, in a word, as bigots.  Their mission is to discriminate against and exclude a marginalized group.  I hoped I might encounter something less stark and more nuanced in the "gender critical"internet discussion group I joined, since some other intersex advocates have had some positive things to say.  But that's not what happened, and a couple of days spent reading and attempting to have conversations left me feeling depressed and sullied.  There were a few positive moments, but they were vastly outweighed by slogging through a lot of LOLing about how stupid a person must be to think they can call themselves female when they were born with a penis.

So, my first question is, why have a few intersex friends had anything good to say about TERFs?  I think I can point to a few things.

1.  The phrase "gender critical" sounds appealing.  My intersex friends are critical of the way sex and gender are understood and enforced in the contemporary West, since this involves unconsented-to surgery performed on intersex infants' genitalia with lifelong ramifications that can be quite negative (loss of genital sensation, loss of fertility, loss of a source of natural sex hormones, and sometimes assignment to a sex with which the child does not grow up to identify).  A group that says they critique gender from a feminist perspective certainly sounds like it would make a reasonable ally.

2.  Intersex people are often uncomfortable with the application of the terms "cis" and "trans" to intersex experience.  The terms apply very poorly because they presume that physical sex is binary (even if gender identities may be nonbinary).  That is, if a person is born genitally intermediate, surgically assigned female, and grows up to identify as a woman, is she "trans gender" because she was surgically genitally altered to become female, or "cis gender" because she identifies with the sex she was assigned at birth?  Either term winds up misrepresenting something about her experience.  (I've suggested the term "ipso gender" in my last post as an alternative.)  In any case, TERFs reject the term cis gender, and this may appeal to an intersex person frustrated with this terminology.

3.  In recent months, there have been a series of "mainstream" articles and online posts in which TERFs' positions have been sympathetically expressed.  For example, one article mentioned by an intersex friend critiqued the term "cis privilege" by caricaturing it as meaning "having a female body is a privilege."  Clearly this is false: because of patriarchy, female bodies are sexualized, framed as weak, and subjected to surveillance.  Tons of cis women don't enjoy getting periods or feeling constantly at risk of an unwanted pregnancy.  Having a female body is not a privilege--but it is also not how trans advocates define cis privilege at all.  Trans people actually define cis privilege as "the benefits one derives from being seen as a 'real' and 'natural' member of one's identified sex" (lack of public scrutiny of one's primary and secondary sex characteristics, being able to use a public bathroom with relative ease, having an ID that matches one's identity, etc.).  Nor do trans people deny, as the linked article claims, that cis people also suffer from gender policing.  Someone who identifies as a woman yet who is very butch can suffer from bathroom panic, and a male-identified person who is quite feminine may face a great deal of street harassment.  That is why trans advocates always fight for laws banning discrimination on the basis of gender identity or gender expression.  But if you read the linked article and took it at face value--why, the arguments of trans women sound regressive and ludicrous and enforcing of binary gender stereotypes.  Trans women are telling "natal" women their privilege is to enjoy being pretty and silent and submissive and having lots of babies, says the author!  If that were true, transfeminists really would be revealed to be patriarchal oppressors in disguise.  Only. . . it's not true.  It's a false characterization on par with saying that "feminists are man-haters."

OK, now we have some ideas about why intersex people might think that "gender critical" camp could be reasonable allies for intersex people.  The next question to address is what did I actually find TERFs to say about intersex issues when they were raised in group discussions?  Clearly the "gender crits" aren't trans allies, but are they nonetheless intersex ones?

The first thing I really want to acknowledge is that it's not all bad.  A couple of points came up where "gender critical" positions did align with intersex advocates'.  Most centrally, since TERFs believe that the "natural" sexed body should be accepted rather than medically altered, a good number of commenters were opposed to performing genital surgery on intersex infants, seeing it as mutilation.   That's a good thing.  And secondly, when I posted about Dutee Chand, an athlete who has been excluded from international sports due to sex-policing of her natural levels of testosterone, I found that at least in situations in which a person was born with vulva, raised as a girl, and has XX chromosomes, the TERF posters believed she should be allowed to compete in women's sports despite having testosterone levels that were considered "male."  Also good!

Well, those positions sound heartening!  Why then do I say that the "gender critical" partisans are not good allies for the intersex community?  Because of these numerous other positions of theirs:

1.  There was a total consensus among the trans-exclusionary feminists that sex is naturally a binary.  The fact that people are born sexually intermediate was somehow said not to undermine this assertion, because intersexuality was presented as a disorder, and, I was informed, "you can't take a disorder and call it a sex."  All intersex people were held to have a true binary sex.  While doctors shouldn't perform cosmetic genital surgery, TERFs asserted they should examine the infant and assign them to the correct binary sex on their birth certificates.  I was told that the correct sex would be based on capacity to reproduce in the "very rare" situations in which that would be possible without surgery, and otherwise on genes.

2.  Removing sex-markers from birth certificates generally, or making a preliminary sex marker amendable at will at maturity to M, F, or a nonbinary category--as suggested by intersex advocates--were thus framed as crazy.  It could confuse the child into believing they are members of a third sex, while "real" intersex people identify as women or men, discussants claimed.  It was presumed to be bad for intersex children, while encouraging trans genderqueer fantasies.  Since TERFs see gender identity as a sort of delusion or myth, the idea that families and society should allow the child to mature to develop and assert their own gender identity (male, female, or something else) is basically incomprehensible. 

3.  Nobody on the site at the time I was on it seemed aware what the result of the sex assignment scheme they described would be.  For example, people with CAIS, born with typical vulvae and developing female secondary sex characteristics at puberty if unaltered by gonadectomy, would be understood as permanently and naturally male, being infertile and having XY chromosomes.  Yet CAIS is often not diagnosed until late childhood or puberty, so either CAIS teens would be forced into gender transitions--a process the "gender crits" frame as impossible--or the TERFs would have to accept XY women.  Meanwhile, people born with a phallus fully masculinized by CAH would be permanently assigned female based on having XX chromosomes, while left surgically unaltered.  Given that the most central tenet of TERF politics is that a person with a penis cannot be female, this is a particularly strange outcome.

4.  I was surprised to find myself repeatedly informed that "intersexuality is a derail" when I raised concerns in conversations.  One reason for this is that being born intersex was framed as vanishingly rare.  Basically this argument held that half the population is made up of "natal women" under threat from men trans-deluded into thinking they have a right to enter women's spaces, while intersex issues only impact a handful of people, and concerns about a minor edge case shouldn't come to dominate a discussion about masses of women-born-women.

5.  The main reason I was told that TERF group members were "far beyond the point of reasonable frustration or tolerance for the intersex derail in conversations about gender identity" is that it was supposedly "only ever brought into conversations" as a distractor by men (that is, trans women) trying to deny the reality that genitals determine immutable binary gender, that "natal" women are oppressed rather than privileged, and that trans women are privileged rather than oppressed.  The fact that I, who am intersex and not a trans woman, was the person raising intersex issues was glossed over.   Intersexuality is presented as a straw man issue beloved by trans women.

6.  Another thing I was told is that most people claiming to be intersex are actually trans gender pretenders.  Now, I as an intersex advocate have spoken before about there being an issue of "intersex wannabes"out there, a problem for our community when they present physically-impossible stories--such as having been born with a full set of female reproductive organs and a full set of male ones--that contribute to disinformation.  But I do not appreciate being told that most people who say they are intersex are liars, and that the "tiny minority" of people who actually are intersex are being used by these men-who-caricature-women, proof that real intersex people should revile trans people.  I can make my own determinations about the true prevalence of intersex status, and who is supporting or exploiting me.  Not to mention that asserting that most people who identify as intersex are in fact lying itself contributes to disinformation about our community.

7.  The main situation in which intersex concerns were actually treated as relevant was in the context of discussions of trans-identified children.  (A particularly overwrought conversation in the group discussed an article which bore the blaring title "Toddler Aged 3 Assessed for Sex Change at London Clinic," which actually just reported that a 3-year-old was assessed for gender identity issues, not that the child was offered any sort of hormonal or surgical treatment.)  A claim made in the discussions of trans-identified children was that for parents to "indulge" this "fantasy" by bringing them to a clinic to be diagnosed, changing the pronoun they used to refer to the child, and/or having the gender marker on their ID changed was analogous to forcing genital surgery on intersex children, and thus a human rights violation that should be banned.  I don't see an analogy at all, but rather an inversion: forced genital surgery performed on infants violates their autonomy, while validating a child in their gender identity supports the child's autonomy.  I see TERFs appropriating intersex concerns about unconsented-to genital surgery to advance their goals.

So: I followed a recent suggestion that "gender critical" politics might be useful to intersex people, and spent several days reading posts and participating in a group for "gender critical" partisans.  What I found was something that left an awful taste in my mouth: a lot of transmisogyny, a denial of the lived reality of trans people of all genders, and an insistence on an immutable sex binarism that frames intersex people as disordered.  I was told that most people who say they are intersex are trans pretenders, using a tiny minority to advance their nefarious goal of insisting that gender identity should be respected and genitals treated as nobody's business other than the person bearing them and their intimate partners.  And I found the intersex community's concerns being co-opted to vilify parents who support their children in identifying with a gender other than that on their birth certificates.

They may call themselves by the intriguing moniker "gender critical," but I believe these trans-exclusionary feminists make very poor allies for the intersex community.

Trans and Intersex Children: Forced Sex Changes, Chemical Castration, and Self-Determination

Children’s lives lie at the center of social struggles over trans gender and intersex issues. If you talk with trans and intersex adults about the pain they’ve faced, the same issue comes up over and over again, from mirror-image perspectives: that of medical interventions into the sexed body of the child. Intersex and trans adults are often despairing over not having had a say as children over what their sexes should be, and how doctors should intervene. Meanwhile, transphobes and the mainstream backers of intersex “corrective” surgery also focus on medical intervention into children’s bodies. They frame interventions into the sexual characteristics of intersex children as heroic and interventions into the bodies of trans children as horrific.

The terms and claims that get tossed around in these debates are very dramatic. Mutilation. Suicide. Chemical castration. Forced sex changes.

We need to understand what’s going on here, because it’s the central ethical issue around which debates about intersex and trans bodies swirl. The issue here is the question of self-determination, of autonomy. Bodily autonomy is the shared rallying cry of trans and intersex activists, though we might employ it in opposite ways. Refusing it to us is framed as somehow in our best interests by our opponents.

In this post we will look at how four groups frame the issue: intersex people, trans people, the mainstream medical professionals who treat intersex people, and opponents of trans rights.

If you talk to people who were visibly sexvariant at birth, you hear a lot of pain and anger and regret about how their bodies were altered. This is crystallized in the phrase of intersex genital mutilation, or IGM. As a result of infant genital surgery, many intersex people suffer from absent or reduced sexual sensation—something mainstream Western medicine presents as unethical female genital mutilation (FGM) when similar surgeries are performed on girls in other societies. There are further sources of pain: as a result of “corrective” surgeries, intersex people can suffer a wide range of unhappy results, such as loss of potential fertility, lifelong problems with bladder infections, and/or growing up not to identify with the binary sex to which they were assigned. It is extremely painful to identify as female and to know one was born with a vagina that doctors removed with your parents’ consent, or to identify as male and to know one’s penis was amputated. Imagine if someone performed a forced change on you--would you not feel profoundly violated?

So the intersex perspective is that no one should medically intervene in a person’s body without that person’s full informed consent. Bodily autonomy is a fundamental right. Nobody except you can know how you will feel about your bodily form, whether you might want it medically altered, what risks of side-effects you’d consider acceptable. Routine “corrective” surgery performed on intersex infants is thus a great moral wrong.

When you speak with trans people, childhood medical intervention again comes up with an air of great regret, but now the regret is that one was not permitted to access it. Almost every person I’ve ever spoken with who wants to gender transition medically, whether they’re 18 or 75, has expressed the same fear to me: “I’m afraid I’m too old!” For a while this mystified me (how is 22 “old”?), until I realized what they meant was, “I’m post-pubertal.” For many trans people, childhood was awkward but tolerable, as children’s bodies are quite androgynous. Puberty, however, was an appalling experience. Secondary sexual characteristics distorted the body—humiliating breasts or facial hair sprouting, hips or shoulders broadening in ways no later hormone treatments could ever undo. Many trans people live with lifelong despair over how so much maltreatment and dysphoria could have been avoided if they could just have been permitted to avoid that undesired puberty.

So for trans activists, advocating for trans children so that they might avoid this tragedy is vitally important. The child’s autonomy is central, as it is for intersex advocates, but here the issue is getting access to medical treatment in the form of hormone suppressants, rather than fighting medical intervention. What trans activists seek is the right of children to ask for puberty-postponing drugs, to give the children’s families and therapists time to confirm that the children truly identify as trans, and fully understand what a medical transition involves. Then the individual can medically transition to have a body that looks much more similar to that of a cis person than can someone who has developed an unwanted set of secondary sex characteristics.

So for trans and intersex people, children’s autonomy is paramount when it comes to medical interventions into the sexed body. No child should have their sex (e.g. genitals, hormones, reproductive organs) medically altered until they are old enough to fully understand what is involved and actively ask for such intervention. Conversely, once a child is old enough to fully understand what is involved in medical interventions into the sexed body, and requests such intervention, then it should be performed—whether the child is born intersex or not.

This is not yet mainstream medical practice, however. Today, one in every 150 infants faces medical intervention into the sexed body to which they cannot object or consent. Doctors routinely perform such “corrective procedures” on babies with genital “defects” and “malformations.” Meanwhile, few trans-identified children are supported in their identities by families and medical practitioners—and great controversy and resistance swirls around them when it does happen.

So let’s look at the arguments made by mainstream medicine and transphobic activists. How do they counter the cry for autonomy, given that self-determination and freedom are such central ideals in Western societies? What we’ll see is that they employ two opposing claims based in medical ethics: the duty to save a life, and the duty to first do no harm. If we want to protect the rights of trans and intersex children, we have to understand these arguments and be able to counter them.

When intersex advocates try to fight the framing of intersex children’s bodies as “defective” and somehow in need of surgical “correction,” mainstream medicine responds with a claim of medical necessity. In some very rare cases, particular intersex conditions can be associated with actual functional problems such as an imperforate anus, clearly a serious medical problem that necessitates surgery. But the vast majority of medical interventions into intersexed bodies take place without any such functional, physical problem exsting. They are responses to a social issue (discomfort with sex variance) rather than a physical one. What doctors do, however, is reframe social issues into medical ones. “If we don’t do this surgery, this child will be mocked and humiliated—“he” won’t be able to stand to pee, “she” won’t be able to have “normal sex,” “it” will never be able to marry. The child will be a social pariah and thus be at risk for suicide.”

Through this line of argument, altering the body of the sexvariant infant is cast as a noble act that doctors perform out of their duty to save lives. To counter this, what we need to do is point out that actual studies of intersex adults show that while we do have a heightened risk of depression and suicide, these are caused by unhappiness with our medical treatment rather than prevented by it. Loss of sexual sensation, feelings of having been humiliated by doctors, pain from years of “repair” surgery after “repair” surgery, and for those who do not identify with the binary sex to which we were assigned, the vast sense of betrayal that those who were supposed to care for us subjected us to a forced sex change—these are what lead to an increased risk of suicide. What would really help is would be for doctors to follow the precept of “first do no harm,” to perform no procedures upon us without our full informed consent, and meanwhile, to provide intersex children and their families with social support.

Invocations of “primum non nocere,” first do no harm, and of despicable medical impositions on the lives of innocents are also raised by anti-trans advocates. Transphobic activists generally frame all medical transition interventions as mutilations, and this rhetoric rises to fever pitch when the issue of trans children arises. Recently, anti-trans rhetoric has framed the medical provision of puberty-postponing drugs as “chemical castration” (e.g. in this blog post).

“Chemical castration” is an odd concept. First off, if you read any medical article on the topic, you will find it starting by pointing out that the term is a misnomer, as none of the medications used in “chemical castration” destroy the gonads. The term is nevertheless employed due its specific history as a treatment being given by court order to “sexual deviants” to suppress their ability to have sex, where some prior courts had employed actual surgical castration. Today, some jurisdictions use “chemical castration” in cases of pedophilia, but it the past it was a treatment imposed on men convicted of sodomy—that is, to gay men in an era in which gay male sex was criminalized. Transphobic activists use the term “chemical castration” to evoke an aura of adult sexual deviance, in a manner calculated to frame doctors who provide puberty-suppressant drugs as sexually abusing children.

There is a curious twist in this matter of “chemical castration,” in that universally when court-ordered in the past, and often still today, it did not consist of testosterone suppression drugs as you would expect. Instead, injections of estrogen and/or progesterone were (and are) given. In essence, it caused a forced sex change. Thus, for example, when codebreaking British war hero Alan Turing was convicted of homosexuality in 1952 and sentenced to “chemical castration,” he found the unwanted sex changes in his body so horrifying and humiliating that he committed suicide two years into “treatment.”

In the case of trans-identified kids today, the use of the term “chemical castration” is thus a double misnomer. Firstly, no child is castrated—instead, puberty is simply postponed so that if the child, family, and therapist all agree later that a medical transition is appropriate, unwanted secondary sexual characteristics will not have developed. Plenty of adolescents are “late bloomers” by nature; in fact, puberty today occurs many years earlier than it did through most of human history, when human diets lacked sufficient fats and nutrients to support early puberties. So postponing puberty carries no significant dangers. Further, the point of hormone suppression is not to cause a sex change, in contrast to court-ordered “chemical castration treatments.” The point is merely to buy time to ensure that the trans child in question fully understands zir gender identity and the implications of medical transition.

So: we’ve seen a lot of charged language, of claims and counterclaims regarding mutilation versus vital treatment, cruel withholding of medical assistance versus the imposition of sex changes on unconsenting children. How should trans and intersex advocates respond?

What I would do is to point out that strange and conflicting ideas about children’s autonomy and free will are presented by our opponents. When specialists in intersex “corrective” treatments speak to parents or write in medical journals, they urge that genital surgery be performed in infancy, before age two and a half if at all possible. They claim that this way the child will not remember the treatment and will thus adjust well to the altered genitals and/or sex status. (As if medical monitoring and intervention did not often extend throughout the child’s life, and the procedures left no scars and caused no loss of sensation, so the child would “never notice.”) The age of two and a half came out of now largely-discredited ideas of a milestone of “gender constancy” occurring then, based upon notions of the developing brain that directly relate to autonomy. Before age 2.5, it was basically argued, the baby is irrational and lacks agency, and thus thinks magically about bodily sex, including accepting the “crazy” idea that the sex of the body can change. So, in urging very early intervention into intersex bodies today, conventional medicine is urging the total avoidance of the child’s rational thought and agency.

When it comes to treating trans children, on the other hand, instead of rushing things, all sorts of actors want to draw them out. Most doctors and clinics only provide transition services to legal adults. Those few who treat trans children are extremely cautious about providing any medical interventions other than the postponing of puberty.

Both of these approaches deny children autonomy over their bodies and their lives.

What we must urge is that society consistently respect the rights of children. No children should ever be subjected to sexual surgery without their consent. No children should be forced to have cosmetic surgery. But as children mature, they become able to consent to medical treatment that they do actively desire.

How old is “old enough” to agree to medical interventions into the sexed body? That answer depends on the given child—but 2.5 is certainly too young, and 18 is in most cases too old. What I suggest is that when addressing a medical practitioner urging genital surgery on an intersex infant, that we ask, “Would you perform a sex change on a child of this age who was not intersex?” Conversely, when facing transphobic activists saying that no one who is not a legal adult can be old enough to consent to medical transition services, we should ask if our opponent would say the same if the child were intersex. For example, a child with congenital adrenal hyperplasia may be born with a penis externally, and a uterus and ovaries internally. At around age 12 or 13, if there has been no medical intervention, that child can begin to menstruate through the penis, develop breasts, etc. Would the opponent argue that the child could not be old enough to say that he identifies as male and wants to take testosterone (or that she identifies as female and has decided that she wishes to have surgery to feminize her genitalia)? Would the opponent argue an intersex pubescent child should not at least be able to take puberty-postponing medications to avoid unwanted penile menstruation if they and their family and support professionals were still unsure whether to commit to any more permanent intervention?

What we must ask is that society treat intersex and trans-identified children consistently. We all raise our children to learn to make good decisions, so that they can lead good lives. We must nurture children’s autonomy as they grow, understanding that there are some decisions only they can make for themselves. To force a person to live in a sex with which they do not identify is cruelty; to impose unwanted bodily alterations unconscionable. Wishing happiness for our children, we must nurture and then defer to their right to self-determination over interventions into the sexed body.