Top of the Pops

I've got quite a numerical mind, and I am always interested in my statistics. I check my hit counter most days, and I enjoy watching what happens as the posts rise and fall in popularity.

Best chart show ever: TOTP

Sometimes a post from a while ago will experience a curious surge in popularity over a few days. Sometimes my blog will appear to suddenly become popular in a new country (Hello, Ukraine!). Why does this happen? I have no idea, but it's fascinating to watch.

What's very interesting to me is that I seem to have no ability to predict in advance which posts will be the most successful or popular. There are certainly some surprises in the Top 10, posts which are much more popular than I ever expected them to be.

Conversely, some of my favourite posts (in a personal sense) don't seem to have done all that well, and again I wonder why this is: am I completely missing my intended audience? While the blog is all about me, the hit counter is all about you, the reader, and shows me where your interests lie.

If this were a glittering award ceremony, I would be announcing the winners from a golden envelope, in no particular order. However, it isn't, and I am not. Instead, I here are my top 10 blog posts by number of hits (as I write, the total hit counter is 373,416).

(1) Jan Hamilton. The winner, with 10,047 hits. No real surprises here: the former soldier turned reporter has attracted considerable public interest over the last few years, and appears again at number 10 in this countdown.

(2) Jaye Davidson. A close second with 9,635. Again, not a surprise. The ephemeral Jaye Davidson sprang to celebrity in The Crying Game in 1992, playing a beautiful transwoman. After a brief appearance in Stargate, in 1994, he retired completely from acting. Ever since, or so it seems, everyone has been asking: what happened to Jaye Davidson?

(3) Female Bodybuilding comes third with 9,051. This is my first real surprise. I can't really account for why this article has been so popular. I suppose the subject matter must be especially compelling.

(4) Women who Crossdress comes next with 6,008 hits. A fair way behind the top 3, this is another surprise to me. Again, I suppose the subject matter must be interesting. While (1), (2) and (3) are quite close numerically, so are the next four entries.

(5) Leah True, with 5,774. This one doesn't surprise me. Like Jaye Davidson, Leah is beautiful, fascinating, and gone from public gaze. A lot of people looking, and I guess they end up here. I've tried to contact Leah and never managed it.

(6) Men With Long Nails, with 5,457. Again a surprise. Why should this subject be so compelling?

(7) Emma Ballantyne, with 5,423 hits. Scottish Emma has the famous YouTube channel, starrynowhere, which has over a million hits. She also allowed herself to be interviewed by me here, though this post (curiously) has only had 3,288 hits.

(8) Helen Boyd Interview, with 4,741. Helen Boyd needs no introduction at all to anyone even remotely trans. Here she answers my questions. Although she is so famous, she has her own very successful and popular website, which means people don't need to come here to find out her latest.

(9) Gender Variants on Facebook brings in 4,021 hits. This topic was very popular a couple of years ago-- though I notice that they still haven't introduced gender variants in my country. Come on, Facebook! Get with the program!

(10) Abigail Austen has rushed into the top 10, despite being one of my more recent posts. Not a surprise, since her latest documentary, and book launch, have brought her once more into the public eye.

Writing is better with nice nails

When I look at this top 10, I can see two clear patterns. First, celebrities (Abigail, Jaye, Leah, Emma). Between them these four are responsible for a lot of internet traffic; no surprises at all that some of it should find its way here (though my article about Caitlyn Jenner has scored only 408 hits). The second group seems to be articles about the boundary (the sometimes uncomfortable boundary) between male and female: female bodybuilders, female crossdressers, men with long nails. In this theme, I've also written about women with beards, and men in skirts. My article about That Whole Bathroom Thing, another ongoing issue, can be found here.

While we wait for the applause to die down and the speeches to finish, I would like to point your attention to some of my posts from the archives, which I think are deserving of a little more attention than they received at the time. These are in temporal order, starting with the oldest. These are some of my favourite posts. Why not take a look, and maybe even leave a comment?

(1) Lyn Tornabene and the Red Queen was one of my better early posts. Written back in 2012, it has gathered in only 574 hits. In it, I discuss the theme of pretending to be something other than your natural self, and how this relates to my own feelings about crossdressing.

(2) The More Things Change... was also one of my favourite posts from 2012, and has managed only 480 hits. It discusses one of history's most famous crossdressers, Lord Cornbury.

(3) Subfuscation! has scored only 427 hits. It's a whimsical discussion of the clothing restrictions facing students at Oxford University.

(4) My article about Japanese artist Yasumasa Morimura has managed only 738 hits, despite featuring Morimura's homages to Audrey Hepburn and Marilyn Monroe.

(5) My article about Alex Reid, a transvestite cage fighter who married a topless model, managed only 861 hits. Are you seriously telling me you don't want to read that one?

The final very interesting hit count is the About Me page, which has scored 9,471 hits, making this page the third most popular overall on the blog. That's very satisfying for me personally. I am always delighted when people email me to say they came across the blog and found it interesting or thought-provoking.

So please keep coming, keep reading, and tell your friends!

Outcomes of Sex Reassignment Surgery

My recent consideration of the book Galileo's Middle Finger and my previous interview with Helen Boyd have prompted me to think again about the science of sex and gender. As I have mentioned many times before, there isn't a lot of hard, reliable science out there.

You might consider that science isn't the best tool with which to view transgenderism. To me, that's a little like saying that counting isn't the best tool with which to view how much money you have.

Opposed: Prof Paul McHugh

Since the study of transgenderism is such a huge field, let's narrow it down to one, relatively well-delineated question: should genetic males be offered sex reassignment surgery? You might already have an answer to this question, one way or the other, but let's look a bit more closely.

Detransitioning is the process whereby someone post sex reassignment surgery, living as the opposite sex, regrets their decision, and returns to their original sex. We know it happens, and that means that sex reassignment surgery isn't for everyone.

Paul McHugh, an eminent psychiatrist, and University Distinguished Professor of Psychiatry at Johns Hopkins in Baltimore, went so far as to discontinue sex reassignment surgery at Johns Hopkins in 1979, after studying the outcomes. He wrote:

McHugh: We saw the results as demonstrating that just as these men enjoyed cross-dressing as women before the operation so they enjoyed cross-living after it. But they were no better in their psychological integration or any easier to live with. With these facts in hand I concluded that Hopkins was fundamentally cooperating with a mental illness. We psychiatrists, I thought, would do better to concentrate on trying to fix their minds and not their genitalia.

You can read his whole 2004 article here. I can see how some of his terminology could be inflammatory, but he comes across as someone who believes what he is doing is right. Before you dismiss him completely, read the whole article. In particular, his review (in the same article) of the previously-misguided surgical treatment of intersex children is very balanced and enlightened, and I find it very difficult to disagree with any of it.

Benefits and harms

Suppose you have heart disease. Your doctor suggests you take aspirin, because there is good evidence that aspirin prevents heart attacks. You take aspirin, confident that you will not have a heart attack, because you are doing the right thing.

But it isn't as simple as that. Not everyone with heart disease will suffer a heart attack, so not everybody needs to take aspirin. And some people who take aspirin will still suffer a heart attack, meaning that aspirin is incompletely successful at preventing heart attacks.

Balanced; benefits and harms

All we can say is that aspirin reduces the risk of heart attack. The actual reduction of risk per person is unexpectedly low. It's only when this small benefit is multiplied by thousands of people across a population that it becomes demonstrable. Multiplied across tens, or hundreds of thousands, aspirin can be shown to prevent hundreds of heart attacks.

But aspirin isn't harmless. As well as its benefits, aspirin causes harms. Again, per individual, these harms are tiny, but multiplied across a population, aspirin can be shown to cause an increased risk of bleeding events. We tend to think of these as risks, but to me (and others) this is an unhelpful word, as it implies that risks are avoidable, where in this case they are not: they are inevitable. It creates the irony that some people will take aspirin and experience only the harms (even though most people expect only the benefits!).

There is therefore a bargain to be struck, between the benefits and the harms of any treatment. In the case of aspirin, we can see that the benefits strongly outweigh the harms, and therefore it makes rational sense to take aspirin. For some treatments, the balance of benefit versus harm is not so clear-cut.

There are also people who are already at risk of having a bleeding event. Those people have a different balance of harm versus benefit. For some of them, it may still make sense to take aspirin; for others, it may make sense not to.

So aspirin is a simple example (there is an excellent discussion of aspirin in this context here on Alvin Lin's blog). This article is about the benefits and harms of sex reassignment surgery.

More complicated than aspirin

Once again, we are faced with a population: people born male who request sex reassignment surgery. It's clear that, if we provide that for all of our population, some will receive benefits, and some will receive harms. Some will receive a mixture of both benefits and harms.

Confusing: statistics

As ethical, and rational people, what we want to do is to maximise the benefits and minimise the harms. Our best efforts may mean that more people have benefit than harm, or more correctly that the total sum of benefit outweighs the total sum of harm. (But it may be hard to judge between a hundred people feeling better, but one person losing their life: which is the greater sum?) If we decide that the balance favours performing the surgery, that's an argument for offering the surgery. If, however, we decide that that the balance favours not performing the surgery, then that's an argument for not performing it.

This is the argument put forward by Paul McHugh, but he is missing one important point: that even if the balance of harm and benefit favours not performing the surgery, this applies to a population, and not individuals, and there may therefore be individuals for whom the benefit is greater. In other words, even if, on the whole, surgery is more harmful than beneficial, there will still be some individuals for whom surgery would be the right thing.

The corollary of all this is that, even if surgery is shown to be more beneficial than harmful, there will still be some people for whom surgery would not be the right thing; in other words, surgery still wouldn't be for everyone!

I'm sorry if I am making your head spin. What's the answer to this conundrum? Science, and plenty of it.

Counting your blessings: estimating benefits and harms

The first question is this: taken as a population seeking sex reassignment surgery, how does the sum of benefit compare to the sum of harm?

You might think that's easy: just find a load of post-op transsexuals and ask them if they are happier since they transitioned. Most of them will say yes. So there's your answer, surely? But a sceptic like me would say: hang on. You might not be counting everyone. Some people might have detransitioned. Some people might have taken their own lives (this number is non-trivial where gender dysphoria is concerned, as this study reminds us). Some people might be so miserable that they declined to answer the survey. This is sampling bias, just one of the many biases potentially associated with research.

I came across this useful paper here at the Bournemouth and Poole Joint Strategic Needs Assessment (JSNA) page. It seems to cover the whole UK, and it has a lot to recommend it: it's short; it contains excellent information including great statistics, and it seems to have a very good idea about the priorities in the care of transgender people. On the other hand, it doesn't say who its authors are; it gives no date, and no sources for its figures. I would really like to know if this is some sort of annual report, and if so, where it comes from.

What it says (in brief) is that sex-reassignment surgery is becoming a lot commoner in the UK, but that trans people face a lot of difficulties in schools, in the workplace, and in their personal and emotional lives. So does sex reassignment surgery result in a greater quality of life?

It's difficult to estimate quality of life. You can't measure it directly; you can only ask people to report it. As a result, it is very prone to error and bias, and people telling the researchers what they think they want to hear, or telling them what they wish were true.

Thankfully for us, Una over at Transas City has done the homework for us, and presents a magnificent, detailed meta-analysis of 34 studies from the literature, together with a very detailed discussion of the strengths and limitations of each study. To save you going through it, the bottom line is this: transsexual treatment (not just surgery) is usually (but not always) associated with a better quality of life afterward, though some problems (such as social integration, difficulties finding employment, and so on) persist. I can't praise Una's article highly enough; she has really put in a lot of hard work to bring this data together.

Meanwhile, Elizabeth Hungerford over at Sex Matters presents four different studies, which suggest increased risk of mortality (including suicide) in transsexuals, increased criminal behaviour, and a disconnect between the subjective reporting of outcomes (most people reported improvement) and the objective reporting of outcomes (a lot of complications were reported). She writes:

Hungerford: As this brief review of long term studies illustrates, positive patient satisfaction should be separated from objectively measurably negative outcomes in order to fully understand the efficacy and “success” of “sex reassignment” procedures. We must be skeptical and refuse to accept emotionally motivated claims of “necessity” that are not supported by long term evidence. We must subject these studies to rigorous, unflinching analysis.

And I really think she has a point. Sometimes, giving people what they want isn't the same as giving them what they need. What should a good doctor, using the principles of medical ethics to guide them, offer the person who asks for sex reassignment treatment?

So where does that leave us?

Cumbersome: scientific research

The ideal scientific study will never happen. In it, a large cohort of gender-dysphoric individuals will present for treatment. They will be subjected to an intense battery of psychological testing, designed to demonstrate every facet of psychological function, and every hint of psychiatric illness. They will then be randomised into at least two arms (preferably three). In one arm, they get full treatment: hormones, surgery, the works. In the second arm, they get the next best treatment: counselling, cognitive-behavioural therapy, maybe antidepressants. In the third arm, they get no treatment at all, but get observed to see what happens if you have no treatment at all. The three groups get followed up for a long period (e.g. a decade) to see what the outcomes are. We decide, based on the result, what the best possible treatment for gender dysphoria is.

The reason this study will never happen falls into several areas. First, to enrol patients in a study, you need to fully inform them of what might happen. Tell someone seeking sex reassignment surgery that they may be randomised to a group which doesn't receive it, and they will instantly withdraw from your study. Second, you need a large cohort of people to get robust results, and it's very difficult and expensive to conduct large studies on large groups of people. Third, the longitudinal followup required means that many researchers cannot devote the time required. A PhD, for example, would normally require all the research to be done in a few years. But unless we wait for a lot longer, we might only observe a "honeymoon period" where everything seems rosy (or potentially the opposite: a period of turmoil and unhappiness while settling into a new life which is ultimately more satisfying). Finally, as described here, nobody really wants to touch this sort of research any more.

One solution: real informed consent

By what means can we identify people, in advance, who will ultimately benefit from sex reassignment surgery? Or who won't? The answer is: we cannot. Nobody can tell the future. Doctors are no more able to tell the future than anyone else. And there are a lot of surgical procedures where the outcome is far from certain in advance. Coronary artery bypass grafting, for example, improves lives for many thousands, but opening someone's chest with a saw and plumbing their major blood vessels into a pump (in order to carry out the surgery) is risky, difficult, and expensive.

Informed: consent

Nonetheless, there is a solution, and it is the same as for any type of surgery. We fully inform the individual of the very best information we have, and let them make the choice. We make the assumption that the adult acting with capacity is the best judge of their own best interests. Note that Paul McHugh has already made up his mind--doctor knows best--and he is happy to make the decision that he knows better than his patients what is best for them. Having decided that transgenderism is a mental illness, he may possibly be more comfortable with the notion that transgender people lack capacity to judge their own best interests. This sort of medical paternalism is (thankfully) well on the wane.

Informed consent for surgery might look something like this:

Sex reassignment surgery is likely to be painful and leave you subject to several complications, including incontinence, scarring, bleeding, infection, wound breakdown, blood clots, and even your own death, though this is very rare. The surgery will be permanent and cannot be reversed. You may not have full sexual function afterward, and you may never be able to experience orgasm. Afterward, you are likely to feel better in yourself, but your risk of suicide will remain high, and you may still experience difficulty integrating into society. If you still want the surgery, sign here.

In my experience, most surgical consent forms tend to stress the negative. They need to be seen to make it clear to the patient that while everyone hopes the surgery will go well, and tries to bring about a great result, that might not actually happen.

But making people clearly aware that surgery might go wrong, and even if it goes right, it won't solve all their problems, is a big step forward from saying "no, you can't have surgery". People should be given this information early and often during the consent process for sex reassignment surgery, so that they can really weigh the decision.

I haven't had sex reassignment surgery, so I don't know what the consent process is like. Those of you who have, please post your experiences and comments below.

Meanwhile, we can only hope that particles of good science continue to be done, and that meta-analysis of those particles can clarify the picture for everyone.

More About Children and Gender

In a previous blog post I discussed two particular parenting styles, which seem especially unusual concerning children and gender. The first was (what was probably) a fa'afafine, a boy raised as a girl in a culturally sanctioned third sex, a practice which occurs in several of the Pacific Islands. The second was about Kathy Witterick and David Stalker, who have refused to reveal the sex of their third child, Storm, with the intention of allowing Storm to discover his or her own gender identity, free of societal expectations.

Storm with brothers Jazz (left) and Kio (right)

As I write this, Storm is now three years old, and still of unrevealed sex. There is a more recent interview with the family here. It seems quite clear that Storm's parents love their three children very much. They seem able to stand aside from any expectation of what their children will be, and just watch what happens. As a parent myself, I find it extremely difficult not to project onto my children some sort of expectation about what sort of adults they will eventually become. In addition, gender-neutral parenting is extremely difficult to achieve, for even the most well-informed and well-intentioned parents.

Witterick and Stocker have (perhaps understandably) provoked a fair bit of outrage. While I admire the unconditional nature of their love, I ultimately think their idea is misguided. Children are not simply free to decide for themselves how the world works. I believe that responsible parents attempt to equip children with both cognitive and moral structures which help them to make sense of the world. (If they don’t, then sure as eggs someone else will: via the TV or the Internet or popular music; even their peers). Therefore, it is inevitable that some parental biases and ideas (and neuroses and hangups) will be communicated to their children. I believe it is an essential part of growing up to weigh those parental structures and decide to keep some and abandon others.

One might, for example, discover that one's child had a penchant for cruelty or mischief. I don't think a responsible parent would simply stand by and admire that ("Aww, bless, there's the kid setting fire to the cat again. Isn't it cute?") but would actually intervene.

Both of those situations are where the parents have decided how they are going to raise the children in a certain way. What happens when the child has other ideas from the parents?

In this powerful and thought-provoking article, Eric Adler of the Kansas City Star describes the situation of "A.J.". Born an apparently normal boy, A.J., now six years old, knows he is a girl.

Then around Christmas, A.J. said it. He took his mom's breath away. They were in a store, walking hand in hand.
"'Mom,'" she recalled him saying. "'Do you know that I'm a girl? I'm really a girl on the inside.'"
It was not a question. It was a statement.
"My child did not say, 'I want to be a girl.' He said, 'I am a girl. How can you not see it? Don't you know?'"
The room went out of focus. She tried to respond.
"I said, 'No. No. I didn't know. The doctors told us you were a boy, so that's what I thought.'"
"OK," her son replied. They kept walking. Her mind spun.
"You cannot be prepared for this as a parent," she said. "It's not in any of the What to Expect When You're Expecting books."
Back home, she phoned her husband. "We have big stuff going on here," she said.

A.J., has one older brother, who seems to be an "ordinary" boy, into trucks and sports and the like.

"We were just parents going to work, sending our kids to day care, and this happened to us," the mother said. "I had never even heard the term 'transgender.'"

Read more here: http://www.kansascity.com/2014/02/26/4850042/i-am-a-girl-transgender-children.html#storylink=cpy

A.J. in her bedroom

The article goes into considerable detail about the parents' reaction. For reasons of confidentiality, they are not named. As comparatively conservative people, they supported their child the best they could, and sought professional advice.

They called Children's Mercy [Hospital] and then Gibbs [Caroline Gibbs, gender counsellor]. They remained cautious and skeptical, wondering whether someone who ran a place called the Transgender Institute might be too apt to diagnose a child as transgender. They sat down with A.J., watching Gibbs for signs of leading questions. Gibbs, as A.J.'s mother recalled, began talking to A.J.
"Can you tell me something about yourself? Are you a boy or a girl?"
"I'm a girl," A.J. said.
"What makes you think you're a girl?"
"I just am," she said.
"Is it what you wear or what you play with?"
"No. I just am," she said.
"Your parents say 'my son' and 'him.' How does that make you feel?"
"I'm really a she," A.J. responded, "'cause I'm a girl. I'm a daughter."
"But they don't call you that."
"Yeah, I know," A.J. said.
Her mother could see her sadness.
The eventual diagnosis: gender dysphoria, which led to weekly counselling.

Both parents were supportive of A.J.'s change in gender and role, and both the school and the other schoolchildren were accepting. However, the parents of the other children were a different matter. Sadly, many of them turned their backs.

In the pickup line after school, parents stopped making eye contact. Invitations disappeared. Some parents said they would call, but they never did.

"It is not something that I expected," said A.J.'s father, "but as a parent you want to do what is in the best interest of your child. Your job is to shepherd them into the world. And if your own family can't be accepting of who they are, how is the rest of the world going to accept them, or how are they going to accept themselves?"

A.J.'s mother wrote a follow-up article, which you can read in full here. This article attempts to deflect potential criticism of her and her husband's approach to their transgender child. From my perspective, A.J.'s parents come across as sensible, concerned, loving and right-thinking people, and therefore this article does a great job. But doubtless other people may hold different views.

I absolutely admire A.J.'s parents for their standpoint. What they have done, in openly supporting their child in this difficult time, is both painful and courageous. It's quite clear this situation is not of their choosing; nonetheless they both seem determined to make the very best of it.

Adler's article goes into some discussion about what therapists do when faced with gender dysphoric children.

Treating and guiding young children identified as transgender remains a thorny issue. Some therapists discourage the transitions. Some remain neutral and allow free gender expression to see what evolves. And some actively support and guide children with their new identities.

Read more here: http://www.kansascity.com/2014/02/26/4850042/i-am-a-girl-transgender-children.html#storylink=cpy

The problem is that nobody knows how these children are going to turn out. Some children, known as "desisters" eventually change their minds and return to their birth gender. Again, nobody knows how common desisters are. The experts quoted in the article consider desisters to be few, but studies from other countries report that desisters are quite common. (Even adults occasionally detransition, as described in my blog post here).

Autism: getting commoner (US figures)

A generation ago, autism was very rare. Then suddenly it seems to be everywhere. Is that because we are facing an epidemic of autism? Maybe. On the other hand, maybe we are just getting better at recognising it. Autistic genius Daniel Tammet describes in his extraordinary autobiography, Born on a Blue Day, that his parents struggled to deal with his stereotyped behaviours and incessant wailing as a child, but labelled him "sensitive".

I wonder if something similar isn't happening with transgender children. A generation or more ago, most parents would just not have listened or sympathised (unless the child were a tomboy!). "It's just a phase, son. Here's a toy gun. Go and shoot something". I know that something akin to this happened in my own upbringing. My boyish behaviours were encouraged, and my non-boyish behaviours discouraged, and my family was educated, kind and enlightened. (And I believe, to a great extent, parenting of the kind I had is still very prevalent).

On the other hand, transgender children seem to be becoming more common. (Now you can even get picture books for children about it). The problem is, how common are they? Nobody knows for sure. There are no clear terms of reference, or agreed standards of diagnosis. In other words, we can't even be sure that the numbers they count in the Netherlands are directly comparable with the numbers in the US, or the UK, or anywhere else. I tend to think that, as with autism, the apparent rise in prevalence is not due to a sudden rise in actual numbers of gender-non-conforming children, but an increase in recognition and tolerance of them.

How should they be treated? Nobody knows for sure, and I can say this with absolute certainty. In scientific terms, it is an evidence-free zone. No amount of professional expertise (so-called "eminence-based medicine") can substitute for good scientific studies-- and there are none.

A generation ago, children with ambiguous genitalia were arbitrarily assigned their most likely sex at birth. This was done, with the very best of intention, by doctors, and supported by parents. It was believed at the time that surgical assignment of sex, together with hormonal and psychological treatment, would be all that was necessary to ensure the child would grow up happy and well-adjusted in their assigned sex. Unfortunately, this was often a disaster.

As they became adolescents and eventually adults, some of those people rebelled against the arbitrary assignment of sex at birth, and transitioned to the other sex. One particularly tragic case concerns David Reimer, born a normal male, whose penis was accidentally destroyed during circumcision. His parents were persuaded he should be raised as a girl, but despite orchidectomy and female hormone treatments, Reimer never accepted his assigned sex. He underwent surgical transition to a man, married a woman and became a stepfather to her children. He took his own life at the age of 38.

Reimer's case is pretty extreme, and the psychologist involved, John Money, seems in retrospect to have been profoundly misguided-- if not an unmitigated quack. Nonetheless, Money reported Reimer's habituation as a girl to have been successful, leading to this becoming the template for the care of many other children in similar circumstances.

Boy: dress

The warning signs are all there. Assuming Money was acting with good intentions (which is questionable), we have a case where a prestigious doctor decides on a course of treatment without doing any sort of studies first. Money brushed aside any evidence that went against his belief: that Reimer was doing fine as a girl. Unquestioning acceptance of Money's technique led to it becoming an accepted, standard treatment. I believe that most of the doctors who performed surgery on intersex children were doing it with the very best of intentions, believing they were doing the right thing. But we now know they were wrong.

Likewise I do not doubt that the clinicians caring for A.J. believe they are acting in her best interests, using the latest medical knowledge. Unfortunately, the latest medical knowledge just isn't up to much. All we have are case series; in effect, anecdote and eminence. There is absolutely no way to be sure that what we are doing now is not going to lead to further problems a generation hence.

What do we actually need? First, we need agreed definitions of what we are studying. Next we need numbers; as many as we can get. Next, we need randomisation into two arms: a treatment arm (say, hormones), and a non-treatment arm. Next we need double-blinding: the non-treatment group should receive placebo tablets instead of real hormones, and the researchers recording the results should be blinded as to which subjects have had which treatment. Next, we need clear, clinically-relevant endpoints. Finally we need time, lots and lots of time, since these outcomes can't be measured in six months or a year but over a decade or more.

There are plenty of good reasons why research like this is cumbersome, time-consuming, expensive, uncomfortable for the participants and difficult to conduct easily. Nonetheless, without it, clinicians treating transgender children are doing no better than informed guesswork. We do have the opportunity not to make the same mistakes as John Money, but do we have the will?

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My thanks to Randy for drawing my attention to the Kansas City Star article. Thanks to Una for pointing out a factual error which I have now corrected.

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Addendum 13th April 2014

My thanks to Heather Colleen for drawing my attention to this interesting article in the New York Times written by the mother of a non-girly girl. What I hear in the article is the perplexity, the uncertainty, but also the love and acceptance, and the lack of hand-wringing or catastrophising. Well worth a look.

My thanks also to JJ Saphir for drawing my attention to this article from the New Zealand Herald, which strikes a very opposite view, and is highly critical of allowing children free gender expression. The author unfortunately trots out some fairly obsolete views in support of his very hardline position.

Gay Football Players

Perhaps just a quickie for this one.

One of my favourite radio programmes is More or Less, a mathematics and statistics programme produced by the BBC. I heartily recommend the podcast, which I adore. A shout out to regular presenter Tim Harford, who is brilliant, funny, quirky and fascinating. Another shout out to series producer and frequent guest presenter Ruth Alexander, who has one of the most beautiful voices ever to tickle my eardrums.

The program styles itself as a guide to the numbers "in the news and in life", and is very, very good at sniffing out numerically dubious reports in the news, claims by politicians, and interesting angles on problems, such as the Tuesday Boy problem, or the wonderful question (answered definitively): if you stacked a 4x4 Lego brick on another one, then added another, and another, how tall would the stack become before the bottom brick is crushed by the weight of the stack on top? (*)

So one of the questions they tackled was this: how many gay professional football players are there? (Of course, you know I mean soccer when I say football). How many can you think of? Not many, I'll bet. The most recent openly gay professional footballer in Britain was Justin Fashanu, and that was 20 years ago. Wikipedia devotes a whole article to the question. Football statistician Bill Edgar, of The Times did some analysis.

First, Edgar made the assumption that the rate of homosexuality among professional footballers was the same as in the general male population. He found varying estimates of the prevalence of homosexuality, so chose the lowest reasonable estimate he could find: 1.5% (see my discussion here), which is still a bit higher than the 1% figure which I suggest.

Looking specifically at Premier League football players, there have been 3,200 of them in the last 20 years. The statistical chance of none of those men being gay is 1 in 1 thousand million million million; 1 in 10 to the power of 23.

Okay, so numbers this large make my head hurt. What does that mean? More or Less says it means that if the whole Earth's surface were covered in white drawing pins touching edge to edge. and just one of them were red, the chance of you picking the red one, at random, is 200 times higher than the chance of there not being a gay footballer somewhere in the Premier League over the last 20 years.

So, mathematically speaking, we can say it is exceptionally unlikely that there hasn't been a gay footballer in the Premier League. We cannot, of course, say how many there have been; we cannot know if the prevalence of homosexuality in Premier League footballers is the same as in the general male population.

It may mean, of course, that gay men are excluded, either overtly or covertly, from the Premier League. It may mean that gay men can become professional footballers, but remain in the closet for fear of hostility from fans, managers, clubs, or media. And Justin Fashanu's career definitely suffered after he came out.

What it shows to me is that acceptance of homosexuality is not as far forward as we all like to think it is. This is bad news for any group seeking integration and equality with what we like to call the "general population".

(*) The answer is 375,000 bricks; a vertical tower of 3,591m (or 2.17 miles) tall.

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Addendum: 26th January 2014

Thomas Hitlzsperger

Top NZ rugby player Ryan Sanders has come out and admitted he is gay, after his professional playing career was over. In the interview in the NZ Herald, Sanders admits to having feigned relationships with women to conceal his homosexuality. The elite rugby players here are the national team, the All Blacks, and Sanders believes at least one of them is gay (and he may be including past members). Statistically speaking, he is almost certainly correct. According to this article, there were 1109 men in 2011 who had played for the All Blacks. That's not far off the figure (3200) used to calculate the British odds, as above.

This article also drew my attention to Thomas Hitzlsperger, a German by birth who played in the English Premier Division. Hitzlsperger came out as gay only a couple of weeks ago, after officially retiring from football in September 2013. According to Wikipedia, Hitzlsperger had a long-term girlfriend, Inga, from whom he split in 2007, just before they married.

What these men have in common is (seemingly) concealing their homosexuality during their careers, only coming out after they have retired. Each has concealed his homosexuality by dating women. Whoever the gay footballers are, they are still keeping it quiet while they are in the public eye. I feel certain that Hitzlsperger is not the only gay Premier Division footballer. Where are the others?

Addendum: 23rd February 2014

Stoney

Well, it's like buses. You wait for ages, and then three come along at once.

The England Women's Soccer team captain, Casey Stoney, has just come out and revealed she is gay in the last couple of weeks.

Meanwhile, across the pond, NFL player Michael Sam has announced he is gay. Almost predictably, anti-gay campaigners protested openly in public (methinks they doth protest too much?), attempting to picket a ceremony at which he was to be honoured. But their protest was drowned, heroically, by 500 students who formed a human wall between Sam and the small group of vocal protesters. This is an extraordinary gesture, and you can read the full story here.

And it has just been announced that NBA player Jason Collins has been given a contract with the Brooklyn Nets. Collins announced he was gay last year-- but found himself without a team. Admittedly, his contract is only for 10 days, but it's a start.

Collins, Stoney and Sam are still within their playing careers; in fact, in the ascendency. Does this mean that a floodgate of gay sports people is about to open?

I am indebted to Rachel for drawing my attention to Casey Stoney. Please feel free to tell me about any other gay sports people you may hear about.

Addendum: 30th April 2014

I have just become aware of the National Gay and Lesbian Sports Hall of Fame, which was established in 2013. It's inaugural list of inductees is very sparse, and includes at least one dead person as well as several organisations (rather than individuals). And, of course, it's limited to the US, though it is (apparently) open to trans people. Nonetheless, it's a step forwards.

Addendum: 5th May 2014

Star player: Saeluah

I didn't think I would be able to do this, but finally, I can introduce a transgender international soccer player. Jaiyah Saeluah plays for American Samoa, officially one of the weakest international football teams in the world.

Saeluah is a fa'afafine, one of a culturally-accepted third sex which exists in the Pacific Islands. In simple terms, fa'afafine are usually boys raised as girls. I have blogged about them twice already, here and here. She is also one of her team's star players. She is fully accepted by her team mates, and her manager, although she is known as "Johnny" when out on the pitch, and she was rejected from the college soccer team when she went to study in Hawaii.

Admittedly, as a player for one of the most inconspicuous teams in the world, it's unlikely that Saeluah will make much of a dent in the status quo. But nonetheless, hers is a triumphant story. They've even made it into a movie, which I can't wait to see.

With thanks to Peter, I can direct you to a Guardian interview with her here.

The Story So Far...

A couple of things prompted this blog post. First, it's the end of the year, which always makes me want to take stock of things which have happened over the last 12 months. Secondly, I came across another blog, Stop Crossdressing, quite recently, and having read quite a few of the more recent posts and discussion, I found myself wanting to repeat on there a lot of things which I've posted on other people's blogs. (Stop Crossdressing has been taken down since I wrote this post).


Vivienne



So I decided that a bit of summing up is in order. I've learned a tremendous amount about myself over the last 12 months, and I've profoundly re-evaluated my views about crossdressing. My plan is that, by putting this all together in the one place, I can crystallise my thoughts (always helpful, I have discovered), and also refer other people to here if they want to know my point of view. Regular readers won't find much that is new, but new visitors will hopefully find all my points here in one place.

For ease of reference, I have grouped everything into headings. Some of this stuff is overlapping, so please read to the bottom before you write in to complain about something!

We are all the same

First, we are all the same (provided we are talking here about men who wear women's clothing). Regardless of whether you call our behaviour crossdressing, transvestic fetishism, crossplaying, or whatever, just about everyone who comes to this site (and just about everyone mentioned on here) has the same inner motivations, which arose, at least in the first instance, for sexual arousal. (I am a "lumper", not a "splitter").

For some of us, those motivations are so strong that they overthrow us; for others, they are less strong and can be managed more easily. But all of us, all the time, feel the same desires and tendencies. For some of us, the fiery sexual component has mellowed into a gentler gratification which may not even involve arousal, but for some of us, it's still all about the sexual arousal.

For all of us, I feel sure, there is no other activity which provides the same relief and pleasure.

Alongside the assertion that we are all the same, but independent from it, is my deeply-held belief that no group is somehow more proper, more meritorious, more deserving of sympathy or recognition, than any other. I believe (and have repeatedly stated) that we have more that unites us than divides us, and that we ought to be generally respectful and courteous to one another at all times.

Crossdressing as an addiction

The concept of addiction is an attractive one for some commentators. Certainly crossdressing behaviour can have features resembling addiction, in that crossdressing desires are sometimes unrelenting and all-consuming. The person would rather be free of those desires, and they cause tremendous self-loathing. And the framework of addiction offers the prospect of rehabilitation, and eventually cure.

But for many common addictions (tobacco, alcohol, drugs, gambling) the initial activity is unpleasant. I still think smoking is loathsome, and I remember drinking my first beer, and hating it. I had to work at it to tolerate it, then enjoy it (which I now do). I have no desire whatever to take drugs, or to gamble (I don't even play the Lottery). On the other hand, I was drawn to crossdressing from my earliest memories, certainly before starting primary school, and the very first activities were pleasurable from the very outset. So I don't consider crossdressing to be an addiction in the same mould as those other things. However, it can certainly become one, if allowed to get out of control.

The morality of cross-dressing

The act of a man wearing women's clothing or cosmetics is morally neutral. I don't consider it intrinsically harmful in any way. In particular, I reject claims that there is somehow a biblical or Christian prohibition against crossdressing.

But crossdressing can be tremendously damaging and harmful. The reason is that many crossdressers seem to pursue crossdressing excessively, and it takes away time and money and other resources which could be better spent looking after a family, or a spouse, or a job. When crossdressing reaches the stage where it prevents someone being able to live a normal life, it's too much.

I frequently use the analogy of golf. Like crossdressing, golf is morally neutral. A couple of rounds a week is fine, but there are some guys who want to play golf all the time; they spend excessively on memberships and green fees, and on the latest clubs and equipment, and their wife might be called a  "golf widow". For those guys, golf is interfering with their ability to lead a normal life and has become excessive. But that doesn't make golf itself intrinsically immoral.

Who is in charge

Amour de moi en femme?

Without doubt, I wish I could be free of my crossdressing desires. They have caused me a considerable amount of personal unhappiness, self-loathing, and marital strife. I am not a "happy crossdresser". It seems I have two choices: either crossdressing is in charge of me, or I am in charge of crossdressing. It's clear for me which of us needs to be in charge.

Deciding that involves making an active choice about the priorities in my life. My marriage is more important to me than my crossdressing. My children are more important to me than my crossdressing. My career is more important to me than my crossdressing. On the other hand, setting aside crossdressing permanently costs too much in terms of mental and emotional effort: I become moody and tense all the time, and am no fun at all to be around. I know that my crossdressing feelings won't go away, no matter how long I desist.

So what I am seeking is a middle ground: to permit just enough crossdressing to assuage my yearnings, but not to pursue it to such an extent that it interferes with my normal life. You might well point out (and I would agree with you) that I am seeking to have my cake and eat it too; that such a balance won't be easily struck. But that's what I am aiming for.

Nobody can sum up my feelings better than old Polonius: This above all: to thine ownself be true.

Autogynephilia

Autogynephilia (or autogynaephilia if you speak British) is the word coined by the sexologist Ray Blanchard to describe "a man's paraphilic tendency to be sexually aroused by the thought or image of himself as a woman". Initially I resisted this description of myself, but after coming across Cloudy's blog On the Science of Changing Sex, I accept it as the only theory which fits all the facts and behaviour as I observe them, in myself and others.

The reason this troubles me is that I had considered that crossdressing was not a sexual thing for me; instead, it seems mostly to be about emotional expression and sensual pleasure these days. However, Blanchard's theory is that it has its roots in sexual arousal, and, though it makes me very uncomfortable to admit it, this is absolutely true for me. On the other hand, although the root of autogynephilia is sexual, sexual gratification isn't (by any means) the only reward which it provides, and emotional and sensual pleasures are comfortably within its purview.

Autogynephilia is also (I believe) the reason that late-transitioning transsexuals (like Caitlyn Jenner for example) desire to change sex, although in most cases by the time transitioning occurs the sexual aspect to it has mellowed into a sensation of comfort or belonging in the female role.

Addendum 22nd September 2015: I am extremely indebted to Alice Dreger's wonderful book, Galileo's Middle Finger, for providing the French translation of autogynephilia. In contrast to what I think is a very clunky and uncomfortable term, in French it is amour de soi en femme, (love of oneself as a woman) which sounds positively lovely.

Crossdressing is common

If you look at my post here, you can see fairly reliable figures from the UK's Office for National Statistics about the prevalence of homosexuality in the population. I had previously read a figure of about 1% of males being crossdressers. A more recent figure from Anne Lawrence says that "up to 3% of men in Western countries may experience autogynephilia". I suspect this might be a bit of an overestimate; one swallow does not a summer make, and I suspect that regular, frequent crossdressers are fewer. We are probably on a continuum of frequency or intensity of crossdressing expression, which makes drawing any line pretty arbitrary. (Are you autogynephilic if you dress once a week? Once a month? Once a year? Or are you autogynephilic if you don't dress at all, but are troubled by daily thoughts about it? How do you decide? I touch on these difficulties in my linked blog post).

What Anne Lawrence also says (and I am sure she is right) is that the number of people who change sex from male to female is rising sharply. Lawrence suggests that this increase is largely accounted for by late-onset transitioners, who previously would have been denied sex-reassignment surgery.

In any case, there are a lot of us out there.

Crossdressing is lifelong and incurable

I believe crossdressing is innate to me. Crossdressing desires have been present from my very earliest memories. Though they have faded from time to time, they have never completely gone away. I do not believe that they ever will. I do not believe that someone can be "cured" of crossdressing in any meaningful way; not any more than one can be "cured" of homosexuality.

One one occasion I met an older crossdresser, who told me that in his youth he had been subjected to electric aversion therapy as a means of attempting to cure his crossdressing. He pretended he was cured just long enough to escape the treatment, before returning to crossdressing, which he had pursued for the rest of his life. It had cost him his marriage, and he seemed deeply unhappy, even though he was dressed at a social gathering. And no amount of military discipline could permanently make a man out of Jan Hamilton.

There is a small amount of evidence that anti-androgens (such as spironolactone) can have some effect at suppressing crossdressing tendencies. However, since the hormonal balance of the human body is akin to an orchestra, to meddle with it carelessly is likely to cause far-reaching and potentially permanent side-effects. I therefore don't recommend anyone to take any hormonal medication without thorough discussion with their doctor first.

Crossdressing tends to be progressive as one gets older; a clear and detailed description of how crossdressing manifests in each decade of life is given in Helen Boyd's wonderful book (which I wholly recommend to everyone) My Husband Betty.

Putting crossdressing aside

Many of my correspondents, and some of the other bloggers I link to, are people who have chosen to set crossdressing aside from their lives. Their motivations vary, from religious or spiritual reasons, through to repugnance at crossdressing, through to a desire to retake control of their lives.

I want to be clear that I wish these individuals nothing but success. I think I have quite a lot in common with many of them (and you know who you are!), and the reason for this is that I share with them a determination that crossdressing will not overwhelm me, and a strong moral sense which keeps me away from the less savoury behaviour of some of my fellow crossdressers.

I don't think that crossdressing can be put aside permanently without considerable effort. It’s sort of like being on a diet. At first, it’s OK to go without chocolate and pizza and the other things you enjoy, but after a while you come to miss them more and more. No matter which way you dress your salad or your rice crackers, you can’t make them delicious or satisfying. And then you find that you are using up all your patience and your energy resisting the urge to have a slice of pizza, and you are moody and tense all the time. You may even accept that chocolate and pizza make you overweight, and all those vegetables are highly nutritious and doing wonders for your digestion (and all that is indisputably true). But still, nothing hits the spot like a fresh hot pizza dripping with melted cheese.

It can be done; some people can manage it for ever, but it costs. I believe people who say they have successfully given up crossdressing and no longer feel the urge to do it are lying to themselves and everyone else; just as I believe people who say they prefer salad instead of pizza are lying to themselves (and everyone else too). You can deliberately choose the salad for all sorts of reasons, and I wish you nothing but the very best of luck, but to insist you don’t like pizza any more makes me highly doubtful.

Intersex and transgender

Intersex isn’t the same as transgender because sex isn’t the same as gender. Sex is a biological distinction (chromosomes, hormones and physical characteristics). Gender is a social distinction (roles and behaviour). And to add a third term, sexuality is about who you want to go to bed with. Usually they coincide pretty neatly, but not always.

It’s absolutely true that sex is not black and white, and neither is gender nor sexuality. Intersex people cannot reliably be assigned to either female or male; some of them have unusual chromosome patterns (karyotypes, such as XXY), and some of them have other syndromes which cause them to develop features of both male and female anatomy. Almost all of them are assigned at birth in to one or other sex, and raised accordingly. I believe that's because parents want their kids to be spared the agony of growing up different. On the other hand, some intersex people, when they become adults, are very uncomfortable with the sex they were assigned to.

I think some transgendered people do probably identify with intersex people (without knowing the science well enough) and use the existence of intersex people to justify their views, beliefs, behaviour, whatever. I can also understand how transgendered people might be slightly envious of intersex people (you might wish you were a man with breasts or a woman with a penis) and why intersex people might be uncomfortable with that.

I think what makes some intersex people uncomfortable about themselves is not the same as what makes transgendered people uncomfortable about themselves. I think most members of both groups are uncomfortable about themselves; I know I am. However, I flatter myself that I do understand the science as well as just about anyone.

I imagine a transgendered person saying to an intersex person: “See, I am just like you: neither male nor female.” I imagine the intersex person replying “You’re nothing like me. You started off as one, and now you want to be the other. Whereas I started off somewhere in the middle.”

As a lumper, I say to both: I understand that you both have different feelings and different biology. But, seen from the outside, you are both people who don’t neatly fit into the categories of male and female. Therefore, perhaps you have quite a lot in common after all (rejection, loneliness, doubt), even if you got there by different routes.

Crossdressing and LGBT

And that brings me on to LGBT. The whole notion of LGBT is exactly this: an attempt to lump together people whose behaviour and predilections don’t quite fit with the "mainstream". Before I started this blog, I had joined a closed internet forum for LGBT academics. I had thought that I would have something in common with them. I was, at the time, desperate to open a dialogue with like-minded individuals, but found (almost) nobody like me there. Though I posted about my own thoughts and fears and concerns, all I seemed to get was a polite concern; nobody (and we are talking about gay and lesbian academics) seemed to feel I had much in common with them. I had hoped to strike a chord, but failed.

As it happens, this blog has done quite well, and I have all but given up visiting that forum. But in the months when I lurked, I realised indeed that I had little in common with the regular posters. I dutifully tried to pitch into some of the conversations, and was treated politely and with tolerance, but without ever developing a sensation of feeling I belonged. And I never felt like attending any of the social gatherings which were held quite regularly. It seemed to me that all I had in common with them was my sense of isolation and self-loathing.

I think, though, for the "general public" (if indeed there are any left when you subtract all the trannies and queers and gays and whatnot), crossdressers are considered to be lumped in with homosexuals. How often have you heard an accusation that because a man wants to wear a frock, he must be gay? And how often have you heard crossdressers insist and demand that they are not gay? Where men are concerned, I think most gay men are attracted to masculine men, not feminine men. So crossdressing isn't an especially effective way to find oneself a gay male partner; Jaye Davidson said something of this kind, and I guess he would know better than most.

Crossdressing isn't an expression of inner femininity

I've left this until the end because I think it is one of the most controversial, and counter-intuitive things which I have discovered. It bears repeating. Men don't crossdress because they are innately feminine. Crossdressers don't want to be like women; they want to be like men think women are. It's true that many crossdressers (and here I include myself) didn't behave like typical boys when younger, and were aware something about them made them different from others, but they didn't actually consider themselves to be girls.

Instead, crossdressers are attracted to women (remember: crossdressers are not gay). It's just, for crossdressers, the attraction to women extends to themselves as a woman (the technical term for this is an erotic target location error). In other words, crossdressing is an expression of heterosexual desire, turned inwards. Anne Lawrence puts it more prosaically, and I refer you to her whole article here:

Thinking about autogynephilic MtF... as men who “love women and want to become what they love” offers a more accurate and more richly informative model for clinicians.

In other words, autogynephilia isn't just a sexual fetish, and to dismiss it as such angers nearly everyone, who insist there is a lot more to it (I know I think so). But it can be conceptualised as a whole suite of romantic or attractive feelings, directed towards oneself as a woman, even though most of us are also capable of directing these feelings outward to a female partner. I suppose that makes me feel a little better about the label of autogynephilia applied to me: it isn't just about the sex thing.

I personally believe that the reason some male crossdressers seek out sex with other male crossdressers, is that the sex partner each is attracted to is not the other one, but themselves in the female role, doing things which they consider it erotic for women to do. Add to that the sexual overlay that many men consider it erotic for two "women" to have sex together, and you have a powerful mix indeed. And indeed, each participant will tell you he is quite sure he isn't doing it because he is gay. See here for Helen Boyd's comment.

I also believe that many crossdressers are more sexually attracted to the woman they see in the mirror than with the woman they may be married to, and Helen Boyd offers plenty in support of this assertion too.

My final piece of evidence in support of this assertion is mentioned above: if you want to suppress crossdressing desires, you don't take more androgens (which, you might think, would make you more "manly"). Instead you take anti-androgens, which suppress male sexual appetite and behaviour. Why does that work? Because crossdressing isn't driven by femininity, but by masculinity.

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Anyway, that's been a lot of useful discovery for just a little over a year. For regular visitors, please do keep coming, and posting your comments; I find them extremely stimulating and valuable. For new visitors, do please browse through; one of my personal favourite, but least-visited posts, is this one.

All the best for 2013,

Vivienne.

How many of us are there?

This is a question which puzzles me from time to time. How many of us are out there?

More specifically (and academically), if you take a large population, say a million people, how many of them are men who crossdress?

It's not an easy question to answer. For a start, given a million people selected at random, there is no guarantee that half of them will be genetic males. For most countries, there is a slight preponderance of one sex over the other. For example, in the United States in 2009, males constituted only 48.4% of the population as a whole.

To further illuminate the problem, we can consider the figures for homosexuality. I believe homosexuality is becoming much more accepted as a lifestyle (certainly in Western countries), and it has been a considerable focus of academic and governmental study. There was an excellent discussion of this by the BBC Radio 4 programme More or Less back in October 2010. You can listen to the podcast for free here.

The UK's Office for National Statistics reported the results of its Sexual Identity and Evaluation Report in 2010. It reported that, based on extensive statistical investigation, that 0.9% of the UK population (equivalent to 466,000 people) are gay or lesbian, and a further 0.5% (equivalent to 229,000 people) identified as bisexual. To complete the picture, about 0.5% of respondents chose other as a response (equivalent to 246,000 people) and about 3% of respondents refused to answer (equivalent to 1.6 million people).

The "other" group could encompass people who are "asexual or have no sexual identity at all", or "disagree with the simplistic male/female gender binary". I suppose those who are intersex or transgendered might possibly fit in this group, though no further comment is made in the report.

More or Less received opinions from some listeners that the prevalences were too low. Some groups thought the figure should be as high as 5 or even 10% of adults. The programme went back to the ONS, and its report makes interesting reading. I have to say that I thought that the ONS's method was extremely enlightened, sensitive and reasonable. I congratulate it on the quality of the report, and I think the numbers are very reliable.

The report makes the point that sexual identity is a very complex and subtle thing. It asked a series of elegant questions about it in three categories:

Sexual attraction: These questions attempt to elicit what sort(s) of people the respondent is sexually attracted to. The attraction can take the form of dreams or fantasies as well as explicit behaviour.

Sexual behaviour: These questions attempt to determine if the respondent has sexual partners of the same sex or opposite sex, or both. Sexual behaviour (the report states) does not necessarily form a basis for sexual identity.

Sexual identity: These questions attempt to describe how individuals think of themselves. This does not necessarily reflect sexual attraction or sexual behaviour, and can change over time.

Sexual orientation can be the result of any of the above.

The report goes on that "no single question would capture the full complexity of sexual orientation". While legislation discusses sexual orientation, the ONS believes that sexual identity is "the most relevant dimension... to investigate, given its relation to experiences of disadvantage and discrimination".

Where does that leave crossdressers? Are we in among the bisexuals? Or do we fall into the "other" group, or even the refusals? There just is no way to tell.

If I were to answer the ONS questions honestly, my answers would look a bit like this:

Attraction: genetic females and very passable crossdressers only.

Behaviour: exclusively heterosexual (which, to be clear, means only genetic females).

Identity: heterosexual male. Would I put "other"? Just possibly. However, I was never surveyed. For my responses to fit with the report, I would need to be surveyed in exactly the same way as all the other respondents. I am confident that I would not refuse to answer any of the questions.

Something like the ONS questionnaire would need to be drawn up to estimate the prevalence of crossdressing in a population. Adding crossdressing or transgender behaviour to this complex mix above would create a whole new layer of confusion.

If we take the situation that an individual born genetically male habitually wears female clothing, there are lots of potential reasons: the individual may make their living as a drag performer; they may feel they were born in the "wrong body"; they may dress for fetishistic or sexual reasons, or there may be any number of other reasons.

I suppose the questions could go something like this. I am really making this up, but feel free to comment on better questions. From my perspective, I am most interested in men who want to wear women's clothing. It seems that women who choose to wear men's clothing have very different motivations, but I am very willing to discuss this point further.

Clothing inclination: This question would seek to determine the inclination or desire to wear clothing normally worn by women. (For me the answer would be something like "almost constantly").

Clothing behaviour: This question would attempt to describe the actual behaviour. (For me the answer would be "infrequently").

Gender identity: This question would attempt to determine the gender identity of the responder. (For me the answer would be "male". I don't feel like a woman or especially want to be one).

I think these questions avoid (as the ONS did) any suggestion of motivation or reason to cross-dress. I don't know why I do it. I don't think anyone really knows, and I suspect the reasons (if they could be found) would be different for all of us anyway.

What's interesting to me is that I absolutely consider myself a cross-dresser, even though my actual behaviour doesn't really reflect that description all that well. In another post I might explore this issue a bit further.

So all we need now is a million people (or, I suppose, about half that number if we want to ask only males) to answer the questionnaire.

In the meantime, there is no definitive answer to this question. The most academic estimate I can get comes from the excellent book Crossdressing, Sex and Gender by Bullough and Bullough, which puts it at about 1%. This figure probably fits quite well with the ONS figures, in that it could easily include all of the "other" respondents plus a few of the "bisexual" respondents too.

What that means is that, although in population terms we are quite few, there are thousands upon thousands, quite likely millions, of crossdressers out there. Raise your glass!