Health & Family

What it means to be transgender: Answers to 5 key questions

John Chase of Durham, center, follows the chants of North Carolina NAACP President Rev. William Barber during a rally in opposition of House Bill 2 in Raleigh on April 25.
John Chase of Durham, center, follows the chants of North Carolina NAACP President Rev. William Barber during a rally in opposition of House Bill 2 in Raleigh on April 25.

As debate rages over HB2, there remains confusion over what it means to be transgender.

In a May  interview  with Fox News, Gov. Pat McCrory continued to defend the North Carolina law that requires people to use public restrooms that correspond to the sex on their birth certificates. He characterized transgender people as “boys who may think they’re a girl.”

Health care providers and researchers who have treated and studied transgender people take issue with that description. Although a person’s feelings are involved in gender identity, experts say imaging studies and other research suggest there is a biological basis for the phenomenon.

Liam Johns, who was born female, talks about the challenges he now faces under North Carolina's HB2 law.

Q: Is being transgender a choice?

A. “Research continues to show that it’s not as simple as ‘I’m a female/I’m a male,’ ” said J. Wesley Thompson, a physician assistant, medical director of Ballantyne Family Medicine and member of the Charlotte Transgender Healthcare Group.

“It’s far more complicated than ‘This is a choice.’ That might be true for a very small minority, but for the vast majority, no one would put themselves through this kind of pain by choice,” Thompson said. “Studies have shown that a transitioning patient loses 90 percent of their family and friends support network. That’s one of the reasons that substance abuse and depression and suicide attempts are so high.”

Dr. Deanna Adkins, director of the Duke Center for Child and Adolescent Gender Care, said she has transgender patients as young as 2. “They are not old enough to consciously just choose to do that. … It is not a choice in any of my patients. It’s really an unpleasant thing to have going on in your body to feel that distress about yourself. I can’t imagine anyone who would choose to do that.”

Q: Is being transgender a mental illness?

A: No. In 2013, the term “gender identity disorder” was eliminated from the Diagnostic and Statistical Manual of Mental Disorders. The term was replaced by “gender dysphoria,” which focuses attention on those who feel distressed by their gender identity.

The American Psychiatric Association, which publishes the DSM, stated that “gender nonconformity is not in itself a mental disorder. The critical element of gender dysphoria is the presence of clinically significant distress associated with the condition.” Experts say much of the distress is associated with societal attitudes rather than gender identity.

Q: Are people female or male at birth?

A: Not always. Duke’s Adkins is one of 20 pediatric endocrinologists who wrote a letter to McCrory objecting to HB2, in part because “there are babies born in whom chromosomes suggesting one sex do not match the appearance of the genitalia.”

The letter said: “This can be due to multiple biological causes such as chromosome abnormalities, abnormalities in anatomic development, environmental exposures during pregnancy, genetic mutations in the synthesis and actions of adrenal and gonadal hormones, and tumors that make sex hormones. For these children, gender assignment at birth is challenging and takes substantial time, sometimes requiring re-evaluation over months to years.”

Adkins said these children would not qualify as transgender, but through them, “we are able to see what happens when we don’t know from looking at a child what their gender is. It allows us to figure out how gender develops.

“There definitely is a lot of literature out there that shows us gender identity is hormonally influenced, influenced by exposures during pregnancy, and affected by your body’s ability to respond to hormones. But the least likely thing is how you are raised,” Adkins said.

A Columbia middle school student and his mother testified on behalf of the transgender community saying "bathroom bill" is unnecessary

Q: How does gender develop?

A: “All human embryos are equipped with the starter kits for both male and female sexual anatomy,” according to a BloombergView article by Faye Flam. “Every part on the male body has an analogous part on the female body.”

Typically, females have two X chromosomes, and males have one X and one Y. “But these are just the starting switches for a complicated process in which genes on various chromosomes become activated and trigger precisely timed releases of hormones,” Flam wrote.

Depending on which switches are flipped and when, there are lots of possible outcomes. “Not everyone comes into the world with a clear-cut sex,” Flam wrote.

In her book “Becoming Nicole,” author Amy Ellis Nutt describes identical twin boys, Wyatt and Jonas Maines, who were adopted at birth in 1997 by middle-class, conservative parents. The twins were healthy, happy and physically indistinguishable from each other. But by the age of 2, when the boys were just learning to speak, Wyatt asked his mother, “When do I get to be a girl?” In the fifth grade, with his parents’ support, Wyatt changed his name to Nicole and is now a transgender woman.

Nutt writes that sexual differentiation of the genitals happens at about six weeks into a pregnancy, but sexual differentiation of the brain, including gender identity, is a distinct process, occurring at a different time and along a different neural pathway.

“Ultimately gender identity is the result of biological processes and is a function of the interplay between sex hormones and the developing brain, and because it is a process that takes place over time, in utero, it can be influenced by any number of environmental effects,” Nutt wrote.

Q: What does research show?

A: Male and female brains are slightly different in structure. In 2013, Spanish researchers examined MRI scans of the brains of 42 transgender men and women. Even before treatment with hormones, the scans showed that specific structures in their brains were more similar to those in the gender they identified with than of those in the gender they were born with.

Also, researchers in Amsterdam examined adolescent boys and girls with gender dysphoria and how they responded to a pheromone-like substance that is known to cause different responses in the brains of men and women. The study, published in 2014, found that boys with gender dysphoria responded like typical females, and girls with gender dysphoria responded like typical boys.

“The interesting thing about that study,” said Thompson, of the Charlotte Transgender Healthcare Group, “is that (responses to pheromones) cannot be influenced by training or environment. The response to odors is from our primal brain. … Research continues to show that there is a discernible difference genetically and on an anatomical basis for the transgender identity.”

Nutt, who summarized the research in her book, noted that female and male brains are not that different overall.

“What gets lost is that society favors conformity, and nature favors diversity,” she said in a phone interview. “What scientists have been able to discover is that gender identity and sexual anatomy is a spectrum. … We can no longer think of transgender people as being some kind of aberration. … We need to think of them as variations.”

The Charlotte group that produced "Souls of Our Students," an anti-bullying video about diversity in schools, has come up with an 11-minute addendum that focuses on transgender students. The four students, two teachers and parent in the new video

Karen Garloch: 704-358-5078, @kgarloch