There is "Biological Evidence for Gender Identity..." but it’s not what you think

Some smart people have confused the issue

from https://dana.org/article/37705/

By the time a scientific controversy percolates down to the popular press, it’s inevitably been distorted. That’s not intentional. Often, reporters don’t have the background necessary to understand the original research, and the nuances get lost amid the catchy headlines and click-inducing stories. Unfortunately, in most cases, readers only have access to the popularized version — rarely to the original scientific articles – so, it can be difficult to separate fact from hyperbole.

Recently, Steven Rosenthal (a pediatric endocrinologist at Benioff Children’s Hospital) published a review article supporting the “affirmative model” for treating transgender and gender-diverse (TGD) youth (i.e., rapid social transition and medical intervention). It appeared in the influential scientific journal, Nature Reviews of Endocrinology. A similar article is scheduled to be published in 2023 in Annual Review of Medicine. As soon as they appeared, both papers were criticized by Jay Cohn (of the Society for Evidence-Based Gender Medicine) in the Journal of Sex & Marital Therapy. (Complete PDFs of all three articles are here.) Then, Cohn’s critique was summarized on the SEGM website here. In turn, some of the information in the SEGM summary was reported on some popular websites, one of which ran the story under the misleading headline, “No Biological Evidence For ‘Gender Identity’ Exists, Group Of Scientists, Researchers Says.” By this time, the controversy had become a quite confused. Unfortunately, that’s the only version most people are going to remember.

What the articles actually said about biology

You’ve got access to all the original articles in the links above. So, you can see if I’m being fair…

When I read Rosenthal’s papers, I was immediately struck by their inherent contradictions. On the one hand, he enthusiastically supports rapid social and medical intervention for TDG youth. On the other hand, he clearly acknowledges a substantial amount of data that argue for a much more restrained approach. For instance, he admits that TDG youth have an “increased prevalence” of several confounding comorbidities (e.g., autism, mood disorders, anxiety, depression, suicidal ideation) all of which make any initial psychological assessment problematic, at best. He goes on to say that there is only a “relatively small amount of outcomes data currently available,” and “only limited mental health outcomes data… available to support current clinical practice guidelines and standards of care for TGD youth.” And, he warns that “the use of pubertal blockers and/or GAHT [gender-affirming hormone therapy] may have adverse impacts on a variety of physiological/metabolic processes” including hypogonadism, growth, skeletal integrity, cardio-metabolic factors, (loss of) fertility, insulin sensitivity, BMI, HDL cholesterol levels, and (most importantly) brain development.

Yet, despite all of these caveats, Rosenthal claims that TGD youth can begin pharmacological pubertal suppression as early as Tanner Stage 2 (beginning at 8 or 9 years old for girls and boys, respectively), if they meet the criteria for gender dysphoria that emerges or worsens with the onset of puberty. Further, he says, there may be “compelling reasons” to begin GAHT before age 16, the age at which most adolescents – if deemed to have sufficient mental health capacity — can give “informed consent.” Frankly, as a Biological Psychologist who’s spent many years working with children, it’s my opinion that neither of these age criteria are reasonable. Even at 16 years old, a young person doesn’t fully grasp the gravity of a decision that will affect them for (at least) the next half century. Certainly, an eight or nine-year-old can’t.

Rosenthal also acknowledges that “current standards of care and clinical practice guidelines… were based on [only] a few short- term to medium-term outcomes studies and a single longer-term study,” and this “paucity of outcomes data raises notable concerns.” Remarkably, however, Rosenthal — who co-authored the Endocrine Society guidelines and a paper outlining the gender-affirmative model — dismisses these concerns, too.

As a research scientist, it quickly became clear to me that there was something very wrong with Rosenthal’s narrative. His dismissal of disconfirming data and failure to heed the caveats that he, himself, presents made it clear to me that the narrative was driven by ideology rather than scientific rigor. Of course, this is not entirely unheard of in science, but the Rosenthal papers are particularly egregious examples.

In his critique of these papers, Cohn begins by reframing Rosenthal’s narrative in terms of five main points, the first of which, he believes, gives “context” to all the others. Although I agree with Cohn’s overall analysis, the way in which he presents and refutes that first key point is what caused the confusion that I noted at the beginning of this essay. It’s confusing not because it’s inaccurate (it captures the gist of what Rosenthal says), but because it conflates a number of concepts that need to be separated. (To be fair, Rosenthal conflates them, too.) In Cohn’s words, Point 1 is “Gender identity underlies gender dysphoria and is a fundamental personal characteristic, suggested to be biologically “ingrained.””

So, this is the basic disagreement: Rosenthal cites several scientific papers that claim to have found some genetic and neurological markers of gender identity. Based on those papers, he argues that if a “personal characteristic” has a “biological” basis, then it is permanent and immutable (“ingrained”). In his mind, this justifies rapid medical intervention. In rebuttal, Cohn debunks the studies that Rosenthal cites. By doing so, Cohn can claim that gender identity has no known biological basis, that it can change over time, and that it does not require swift medical intervention. Unfortunately, both Rosenthal and Cohn have confused these issues. Let’s sort them out.

First, Rosenthal argues that TGD youth seek medical services to bring their physical sex characteristics into alignment with their “gender identity,” which he defines as “their inner sense of self as male or female or elsewhere on the gender spectrum.” This is not an unreasonable definition of the term “gender identity.” People are free to self-identify in any way that they wish. You don’t have to agree with them but it’s their prerogative. Second, Rosenthal recognizes that one’s subjective “gender identity” exists separately (and is distinct) from sex (which it is). Although, I should note that Rosenthal confuses sex (being female or male) with intersex conditions (developmental anomalies) which, of course, do not represent unique sex categories. Because Rosenthal defines “gender identity” as an individual’s subjective self-perception, it follows logically (in his words) that “gender identity can only be assumed and not known until an individual reaches a particular level of psychological development and self-awareness.” Fundamentally, this is true. In fact, it’s a trivial statement that’s true by definition. I can’t know what you think about yourself until you can tell me. Of course, this does not mean that I have to agree with you, or affirm your self-perception, or even think that you’re in touch with reality… It just means that your self-perception is your self-perception. It’s unknowable to anybody else until you reveal it.

Rosenthal also correctly explains that gender identity is distinct from gender expression, gender roles, and sexual orientation. In his words, “… a girl could display masculine behaviours but exclusively identify as female, or a boy could display feminine behaviour but exclusively identify as male,” and either could be attracted to either sex. Again, this makes sense and is consistent with what we know about people.

The problem arises when Rosenthal (and others) confuse gender identity, self-identifying as a TGD person, and the fundamental principles of biological psychology. It’s this confusion that’s hobbling our ability to understand — let alone discuss — the core issues that revolve around sex and gender.

First, we need to recognize that “gender identity” is neither an easily identifiable thing, like a brain or a leg, nor a clearly defined biological condition, like being pregnant or hypothermic. The term is a metaphorical category — as are all psychological terms — that refers to a variety of different self-perceptions each of which will be represented by a variety of unique brain states. Hence, “gender identity” is a product of biology because brain activity is biology. For instance, although you and I may self-identify using a similar term (e.g., “liberal” or “conservative”), our belief systems are going to differ somewhat because, by definition, we think differently. The term, “liberal,” for instance, is not going to mean exactly the same thing to me as it does to you. Consequently, our belief systems will be represented by different brain activity patterns. However, even if our subjective identities were precisely equivalent, they would still be represented by somewhat different brain activity patterns because we are unique people with unique brains.

By Rosenthal’s own definition, “gender identity” is a subjective self-perception. As such, it can’t be represented by a specific, identifiable brain structure, a discrete set of brain cells, or a specifically identifiable pattern of neural activity (as Rosenthal suggests). That’s not how brains work. However, the fact that you can’t point to a specific structure or pattern of brain activity and say “Look, there’s your gender identity,” doesn’t mean that it’s not a product of biology. In fact, our self-perceptions (or “identities”) are emergent properties of widespread neural network activity that varies from time-to-time within an individual and between individuals even if they claim the same self-perception. That means that my self-perception can’t be “discovered” by looking for some definitive biological marker. Nor can I compare the brains of people with different self-perceptions in order to find the self-perceptions’ root cause. Consequently, Cohn’s debunking of studies that fail to find identifiable biological markers for “gender identity” is beside the point. No study is going to find definitive genetic, hormonal or structural evidence for a subjective point of view. That makes no sense.

By the same token, Rosenthal is absolutely wrong in thinking that because gender identity is underpinned by biology, it is “ingrained,” deterministic, or that it won’t change over time. He is also wrong in thinking that we may have (or will have) the ability to see the imprint of “gender identity” in an MRI, blood test, or DNA sequence. These fundamental misunderstandings are embedded in both of Rosenthal’s papers. In his words, “[There is] “compelling evidence that biology contributes to gender identity development (with the correlate that gender identity, like sexual orientation, is ingrained and not a ‘choice’).” Although Rosenthal’s premise is true, the “correlate” does not follow from the premise. It’s just (erroneous) speculation.

Conversely, of course, the fact that self-perceptions don’t show up in an MRI, blood test, or DNA sequence does not mean that they don’t exist, or that they’re not a product of biology. That’s a misunderstanding held by many of Rosenthal’s critics.

So, when Cohn writes this, he’s absolutely correct:

In sum, there is no currently available test (brain, DNA, or otherwise) that can reliably differentiate between a trans-identified and a non-trans identified person, which Rosenthal (2021) acknowledges: “(n)o currently available laboratory test can identify an individual’s gender identity”

That’s true for the same reason that there is no test “(brain, DNA or otherwise)” that can reliably differentiate between someone who identifies as an extra-terrestrial lizard-person (like Durek Verret), and someone who identifies as a human mammal. But that doesn’t mean that these self-perceptions aren’t influenced and underpinned by biology.

Cohn also correctly points out that “People vary in the intensity of their gender identification and in the permanence and completeness of this feeling. One’s feelings of being a man and/or woman may fluctuate…” (from Bockting, 1999). This statement is entirely consistent with what I know about biological psychology. Our self-perceptions can — and often do — change over time (as do our brains). This is precisely why there are large cohorts of people whose gender identification changes as they mature, and who choose to detransition. In fact, it makes no psychological or biological sense to assume that a self-perception will not change over time.

I find it particularly interesting that Rosenthal, himself, wrote that “Compelling studies have demonstrated that gender identity is not simply a psychosocial construct but probably reflects a complex interplay of biological, environmental and cultural factors.” Of course, it does. Because every human characteristic “reflects a complex interplay of biological, environmental and cultural factors.” In fact, this statement is tautological (true by definition). There are no factors other than biology, environment, and culture that could influence gender identity. Consequently, because we know that biology is dynamic, as are the effects of environment and culture, there is absolutely no reason to assume that “gender identity” (which they create) would be rigid, immutable or determinant as Rosenthal claims.

So, let me add a few words to a quote from Rosenthal to make his statement more accurate: “…by shedding light on the role of biology, [and environmental factors, and cultural factors] in gender identity development, it is hoped that such knowledge can lead to de-stigmatization, greater acceptance and improved quality of life for individuals with diverse gender identities.” Now, that makes sense to me.

There’s one additional point to be made about this statement from the SEGM summary: “there is no brain, blood, or other objective test that distinguishes a trans-identified from a non-trans identified person.” This is true and, most likely, it’s always going to be true. The reason is that “trans-identified” and “non-trans identified” do not refer to specific, discrete groups of people. They, too, are categories each of which contains a very diverse group of individuals with very different motivations, personality characteristics, self-perceptions, and points of view. Consider this analogy: There is no single diagnostic test that can determine if someone is on the autism spectrum or has Alzheimer’s, but that doesn’t mean that these conditions don’t exist, or that they’re not biologically based.

So, you can see how the headline, “No Biological Evidence For ‘Gender Identity’ Exists…” is misleading on two levels. First, there is biological evidence that gender identity exists: Human beings — which are biological entities — hold these beliefs, report these beliefs, and behave according to these beliefs. The rather naïve, and erroneous assumption behind the headline is that ‘real’ biological evidence should be an identifiable set of cells, genes, or molecules rather than the existence of an emergent psychological phenomenon that is the product of a dynamic biological system.

The key point to remember is that cells, genes, or molecules don’t have gender identities any more than your lungs or liver can fall in love. Complex psychological phenomena — like gender identity — only exist at the level of the whole, intact person. The tacit assumption that because our mental states are products of biology, there should be a specific diagnostic test that reveals their existence is a complete misunderstanding of how biology works.

The most compassionate, kind, and thoughtful approach to this issue would be to decouple ideology, politics, and the financial interests of the biomedical industry from the science, and work cooperatively to better understand humanity in all its diversity. In Cohn’s words, “There are serious challenges in deciding how to best support those currently suffering gender dysphoria, given how little is known about this complex condition. Accurately describing what the evidence currently says and does not say, and what further evidence is needed, is crucial.”

I agree.

Epilogue

Unfortunately, people have done a lot of bad things because they misunderstood biology. So, it makes me very uneasy when I hear people say that they’ve ‘discovered’ the ‘biological cause’ of some psychological condition or, conversely, that the condition is socially constructed without any biological underpinnings. Both of these extreme positions are ill-informed (i.e., wrong). Someone convinced of the former would be highly motivated to intervene with drugs or surgery to ‘fix’ a perceived psychological problem irrespective of empirical evidence to the contrary. Someone convinced of the latter, would be more than willing to manipulate a person’s life so as to shape them in whatever way they thought best, again, irrespective of evidence to the contrary. Consider the history of lobotomies, or the career of John Money (who popularized the term “gender identity”).

Unfortunately, the current conversation about gender identity is being driven (to a great extent) by people who have a naïve and simplistic understanding of biology, and a zealous belief that they know just how to manipulate it in order to permanently ‘fix’ what they think is a unitary psychological phenomenon. However, because both biology and psychology are complex, and people are remarkably diverse, the same ‘fix’ will never work for everyone… just like the same antidepressant or blood pressure medicine doesn’t work for everyone.

Diversity, including neuro-diversity, should be recognized and valued. Every individual should be respected, accepted, included, and have the opportunity to live the best life that they can. For some people, pharmacological or surgical intervention may be the best option. However, by definition, that singular solution is not appropriate for everyone. Unfortunately, the most zealous proponents of that singular solution are doing a tremendous amount of irreversible damage to the young, the vulnerable, families, women, and many of our institutions. I think that’s misguided and unacceptable.