CHAPTER ONE – UNDERSTANDING TRANS
This book is about the law as it relates to trans individuals, in particular those with the protected characteristic of gender reassignment or to whom the Gender Recognition Act 2004 applies. But to put those matters in context, the position and life experiences of trans individuals needs to be understood. Gender Reassignment is still the rarest of the nine protected characteristics which form the basis for the Equality Act 2010. Accurate figures are hard to come by, but a good estimate of the numbers of trans individuals in the population might be between one in two thousand to one in five thousand of the UK population. Such a number means that most of the UK population will not know a trans individual personally, and most small to medium sized employers will not have a trans employee.
It is very important that there are ways for employers, employees and others to learn about the needs and life experiences of trans employees. Just as in a nation with a Christian-based state system had to learn and adapt to Muslim employees’ need to attend Mosque on a Friday, the needs and aspirations of trans individuals need to be understood.
Trans is also not one ‘thing’. We are increasingly understanding than many individuals do not define themselves on a gender binary. Complex gender identities pose challenges beyond the (far from) simple transition from one binary gender to the other in terms of pronoun use, and provision of gendered or gender-neutral facilities.
Origins
There is still considerable scientific debate about how certain individuals exhibit gender dysphoria (ie distress about their assigned gender) or gender variance. There is some evidence that genetics play a part (it runs in families) and some evidence that nurture has an effect (likelihood of male to female trans child increases with mother’s number of previous male pregnancies). However, it arises, gender dysphoria / gender variance is very real to those who experience it.
Childhood
Many trans individuals report being aware of a ‘difference’ by age 5 or 6. An element of gender variance is entirely normal at that age and many such children revert to a gender identity which matches their birth sex by their teenage years.
But many do not, and experience considerable distress as the effect of male or female puberty differentiates their physical appearance and secondary sex characteristics such as breasts and hips for girls, voice, growth spurt, facial and other hair and body mass and musculature for boys.
Until relatively recently, no treatment was available to affect or interrupt puberty and trans individuals could do nothing but wait until adulthood to take steps to have their physical appearance match their affirmed gender.
More recently, puberty blocking drugs have been used in trans teenagers with the object of delaying puberty to give the individual time to develop the emotional maturity to make the life-changing and at least partially irreversible choices that gender transition will entail. Some controversy surrounds the use of these drugs as, inevitably, a long-term body of evidence as to their effects has not yet been built up. Real ethical dilemmas are involved. How, for example, could a control group of children be created who ask for such treatment and are denied to ‘see’ if they would have been happy without it? Some evidence can be gleaned from the (very small – 1 to 3%) number of ‘detransitioners’, those who regret the transition they undertake.
There are particular concerns about the growth in the number of girls who wish to transition to boys and the high instances of individuals presenting with gender variance and autism.
Trans in adulthood
Many readers will be familiar with the 2015 film in which Eddie Redmayne played Einar Wegener / Lili Elbe, the Danish painter who transitioned from male to female in the 1920s but sadly died from the complications of tissue rejection in 1931 in Dresden Women’s Hospital when a pioneering transplant technique was used to attempt to give her female bodily structures. English pioneers were: Michael Dillion (1915 to 1962), an Oxford women’s rowing blue who transitioned from female to male; Roberta Cowell (1918 to 2011), a WW2 Spitfire pilot and racing car driver who is regarded as the first British woman to undergo gender reassignment surgery; and April Ashley (born 1935), who transitioned from male to female, merchant seaman turned model.
Through the 1950s 60s and 70s, the leading trans psychologist was Harry Benjamin (1885 – 1986) an Austrian who had emigrated to the USA in the 1930s. He set up the International Gender Dysphoria Organisation which published agreed care standards for the treatment of trans individuals – sometimes referred to as the Benjamin Guidelines. That is now the World Professional Association for Transgender Heath (‘WPATH’) and the current ‘Standards of Care’ – Version 7 from 2012 – set out the internationally agreed guidelines for care of those expressing a desire to change their gender. This can be a useful document for an employer to obtain when managing a transitioning employee as it is a clearly-written, comprehensive document and may avoid asking the transitioning employee embarrassing questions.
Transition Process
There are, essentially three stages.
First, an individual presenting with apparent symptoms of gender dysphoria undergoes a period of psychological assessment aimed at deciding (1) whether they are in fact trans, and (2) whether they have the stability to engage with the challenges that transition will bring.
The wait for this first referral if being treated on the National Health Service can be, at the time of writing (March 2021) as long as three years from GP’s recommendation to being seen by one to the specialist clinics in the UK. This can lead to the dangerous practice of individuals self-medicating with cross-sex hormones and also to better-resourced individuals seeking to find a specialist doctor for a private referral. This can be expensive.
Secondly, once a WPATH-compliant assessment has been completed, the transitioning individual is then prescribed cross-sex hormones, under the supervision of an endocrinologist. Such supervision is important as hormone levels can affect liver function and other bodily systems. Female hormones will cause softening of the skin and redistribution of body fat in trans women. Male hormones will cause trans men to develop male pattern facial hair (and, in time, male-pattern head hair loss), increased muscle mass and breaking of the voice. Through this period trans women often have (long, expensive and painful) treatment to remove male-pattern body hair.
At some time during the second part of the process most trans individuals will socially transition. That is to say, begin to live in the gender they identify with. Trans individuals face a certain “chicken-and-egg” situation. They have to transition to justify the physiological and other interventions that will make their transition more complete, but they have to do so before some or all of those interventions have been provided. The process of transition can be a difficult time, at least in its early stages. Social conventions – as simple as who steps first into a lift, how one person greets another, and the like – have to be relearned.
Psychological assessment continues during the second stage to assess the appropriateness of gender confirmation surgery – the third stage of the process. In trans women this often includes orchidectomy and use of the scrotal and penile skin to line a surgically-created neo-vagina. In trans men a bilateral mastectomy is usually performed, and less commonly, reconstructive surgical techniques are used to create a penis.
A number of cosmetic surgery techniques have also been developed, particularly to assist male to female transitioners. These are often focused on facial features and hair transplants, hair line lowering and reshaping, redirection or removal of brow ridges, shaving the bony rim of the eye-sockets, rhinoplasty, cheek implants, lip lifting and bony surgery to reduce the outline of the jaw and finally shaving of the Adam’s Apple are commonly carried out. This surgery is generally not available on the NHS and can cost several ten of thousands of pounds. Sometimes vocal cord surgery, breast augmentation, and even rib reductions are carried out. There are a number of centres for so-called ‘facial feminisation surgery’ in different parts of the world.
Complications are that later transitioners may have denied, fought against or tried to ‘bury’ the fact that they are trans. They may have married and had children. They may not have informed partners of their personal feelings. While many family members accept transition of a relative or partner, many do not, and so transition can result in divorce and ostracisation from close relatives.
Complete transition in trans women will remove the testes and for trans men the womb and uterus. It is, therefore, regarded as good practice to offer trans individuals the chance to freeze sperm or ova so that, if a later time they wish to conceive children, that can be made possible by in vitro or other techniques.
Trans individuals may continue living in the same place, working for the same employer but a number use the time of transition to move location and employment.
There is clear evidence that the vast majority of those who have transitioned then live happier more fulfilled lives. There will, however, be a tiny number who decide that transition was wrong for them, or, having fully transitioned, decide to return to their birth sex and gender. Life can be difficult for so-called de-transitioners, as they may have had treatments or interventions which make that return incomplete or unsatisfactory.
Trans individuals will remain on hormone treatment for the rest of their lives. Complications can occur with medical treatment. For example, trans women do not have a cervix and so need not to be called for cervical smear tests but they do retain a prostate gland and so may be at risk of prostate cancer. Conversely, trans men are spared the risks of prostate or testicular cancer but if they retain a womb or uterus they may experience cervical cancer. Issues of confidentiality related to medical treatment will be clear from these examples.
Many trans individuals, particularly those who have transitioned young, settle easily and undetectably into their new gender role.
Sexuality and gender are separate and should not be confused. However, many trans people struggle to know when in a new relationship they should make their trans status plain to a potential partner.
Much has changed for trans individuals in the century since Lily Elbe transitioned in the 1920s. No doubt more will change in the century to come.