Shifting Sands

Although it's over a year since its release, I came across this amazing publication, and I wanted to give it wider recognition.

The Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG) is the medical college responsible for setting training standards for doctors specialising in the field of Obstetrics and Gynaecology in Australasia. So it's a very large, prestigious, academic organisation.

As most medical colleges do, it publishes a flagship academic journal; but also a more informal publication, O&G Magazine, which I admit I had never come across until I saw a pile of them lying in my hospital. The top one caught my eye, because it was colourful, and because it looked like Tetris (which is one of my favourite games). When I looked closer, I saw that the theme of this particular issue was "LGBTQIA", so I picked it up to have a read. I was immediately captivated. Best of all, the entire issue is available free online here.

Let's start with the editorial, from incoming RANZCOG President Dr Vijay Roach:

Roach: This issue of O&G Magazine addresses an important aspect of social, cultural and clinical life in Australia and New Zealand. Members of the LGBTI community have experienced a long history of marginalisation and discrimination, often to the detriment of their physical and mental healthcare. While the College acknowledges a diversity of opinion in the community and among our members on many issues, on one thing we are united: RANZCOG believes that every person, independent of their sexual orientation, has the right to high-quality medical care. 

In 2017, the RANZCOG Board issued a statement on same-sex marriage which read, in part '… the Board affirms its support for marriage equality and calls upon the Australian Parliament to ensure equal opportunity for lesbian, gay, bisexual, transgender and intersex (LGBTI) Australians in same-sex relationships and their families …' I was proud to be a member of that Board and grateful to then-President Prof Steve Robson for his leadership.

In this issue, the O&G Magazine editors have assembled a diverse series of articles relevant to the care of the LGBTI community. It is compelling reading and relevant to everyone’s practice.

The list of articles is impressive:

Fertility options for gender and sexually diverse people (Bronwyn Devine)
Rainbow IVF (Sarah van der Wal)
Gender dysphoria (Simone Buzwell)
Gender dysphoria: a paediatric perspective (Noel Friesen)
Fertility preservation in the transgender child and adolescent (Tamara Hunter)
Intersex: variations in sex characteristics (Jennifer Beale)
What do intersex people need from doctors? (Morgan Carpenter)
Hormonal treatment of the transgender adult (Rosemary Jones)
Surgery for transgender individuals (Charlotte Elder)
LGBTQIA gynaecological screening (Kimberley Ivory)
Takatāpui (Elizabeth Kerekere)
Tekwabi Giz National LGBTI Health Alliance (Rebecca Johnson)
Glass closets and the hidden curriculum of medical school (Amy Coopes)
Australia's queer history (Robert French)

I read these articles with two sets of eyes. The first were my medical eyes: was this the sort of thing that, as a doctor, would be helpful for me to read? The answer is clearly yes. The second were my transgender eyes: was this the sort of thing that, as a trans person myself, I would want doctors to read and know? The answer is also a clear yes. There is no doubt that transgender people are becoming more and more visible; their care has been, in the main, not that great; most doctors have very little training in care of transgender people, and reliable resources for doctors to draw upon are few.

The various authors all have special expertise and interest in their various fields, which is commendable. But it's the range of subjects which strikes me as particularly noteworthy. I've sometimes felt that the T is kind of tacked on to the end of LGB as an afterthought. But here we are, right in the middle, with articles dealing with not just hormones and surgery but issues like fertility and childhood and emotional wellbeing. Amazing.

I was pleased to note that the tone of all the articles was spot on, from the acceptance of the individuals, to recognition that care matters but is frequently lacking, to pragmatic information and guidance for practitioners.

There are several points which are very much worth making about a publication of this type.

(1) First, it's great that a major medical college is being so overtly inclusive. That alone is magnificent. RANZCOG is setting an example for others to follow. There has been lots of Twitter support for the issue.

(2) Second, most medical colleges publish guidelines for the care of patients with X condition. What strikes me about this one is a subtle but powerful shift in tone: not "this is what these patients are like" but "this is us, and that's OK". As Amy Coopes points out in her article, there is still great stigma in medicine if you are gay or non-binary. So a publication like this is extremely affirming. As a transgender person with a medical degree myself, I immediately wanted to reach out and make contact, so I wrote to RANZCOG and congratulated them on their magazine (and I’m not the only one: there is a very heartfelt response from a gay obstetrician in the following issue here).

(3) I wouldn't have necessarily expected O&G to be the specialty which would deal with the care of transwomen. Post-transition, care could potentially be complex, since O&G specialists are more used to the care of people with a uterus and vagina than a prostate gland. But this issue seems to be saying to its readers: don't panic, you can do it! It's started me discussing these issues with some of my colleagues much more openly than previously.

Whether you are medical or not, it's well worth having a browse through this magazine. If you're aware of any other medical organisations being explicitly rainbow-inclusive, please let me know.

Sex and Gender in Sports - Part Two

In my previous article I considered the distinction between male and female athletes competing in top competitions such as the Olympic games. Right at the nub of the issue is whether women with naturally high levels of testosterone have an unfair advantage against women with lower, or "normal" levels of testosterone.

But what about transgender or transsexual athletes? Those born in an apparently ordinary male body, who legitimately transition to the female sex? What happens to them?

Renee Richards

Renee Richards is the first example I have to offer. Born Richard Raskind, the child of two doctors, Richards was a successful male athlete, and also obtained a medical degree. In 1975 (which puts her age at 41), she pursued a career as a professional woman tennis player. However, in 1976 the US Tennis Association had introduced Barr body testing (a type of genetic testing) that year. Richards refused to take the test, and was therefore banned from top tennis tournaments, the US Open, Wimbledon and the Italian Open that year.

Richards took the US Tennis Association to court, alleging discrimination by gender in violation of her human rights. She won her case, and was allowed to play in the 1977 US Open tournament.

Richards' tennis career was quite short-lived, and she retired from professional tennis in 1981, just 4 years later, and returned to medical practice in ophthalmology.

Richards' case provoked considerable discussion. Official sports governing bodies were very uncomfortable. According to Wikipedia, the US Olympic Committee stated:

IOC: There is competitive advantage for a male who has undergone a sex change surgery as a result of physical training and development as a male.

And indeed, it's hard to argue with that viewpoint. But in addition to official perplexity, Richards faced consternation from the general public too. My correspondent Rhonda wrote "I recall it being said that Renee had an advantage because she competed in a new category, unique to her: 'Mixed Singles'." And even her own fellow athletes were unhappy: when Richards was allowed to play as a woman, 25 of 32 competitors promptly withdrew in protest from the Tennis Week Open.

In this article describing her life and career, written by Emily Bazelon, Richards herself comments on her status as a transsexual athlete. I quote the final paragraph in its entirety:

Bazelon: The science of distinguishing men from women in sports remains unsettled. And Richards has come to believe that her past as a man did provide her advantages over competitors. “Having lived for the past 30 years, I know if I’d had surgery at the age of 22, and then at 24 went on the tour, no genetic woman in the world would have been able to come close to me. And so I’ve reconsidered my opinion.” She adds, “There is one thing that a transsexual woman unfortunately cannot expect to be allowed to do, and that is to play professional sports in her chosen field. She can get married, live as woman, do all of those other things, and no one should ever be allowed to take them away from her. But this limitation—that’s just life. I know because I lived it.”

Michelle Dumaresq

Wikipedia has a list of transgender athletes, both female-to-male and male-to-female. There are, unsurprisingly, few Olympic type events, though there are cyclists, such as Canadian mountain biker Michelle Dumaresq, and fighters, such as American mixed martial artist Fallon Fox. Caitlyn Jenner is of course mentioned.

In 2003, the International Olympic Committee drew up regulations to cover transsexual athletes. To me, at first glance, they seem pretty reasonable:

1. The athlete must have undergone sexual reassignment surgery, including changes to the external genitalia and gonads.
2. The athlete must be legally recognised in their desired sex.
3. The athlete must undergo hormone therapy for at least two years.

These guidelines were modified in 2015, due to recognition that it might not be acceptable to require surgery in otherwise healthy people, and that some countries refuse to grant legal recognition to people who change sex. Therefore, the regulations were changed. The requirement for surgery was dropped, and the only stipulation now requires that the athlete's testosterone level be under 10 nmol/l. (See my previous article for why this might be problematic).

Chris Mosier

As for these games, the UK Daily Mail reported that two unnamed male-to-female athletes were considered for inclusion in Team GB to compete in Rio, but the Internet has been silent about whether they managed it. Meanwhile, Chris Mosier competed as a triathlete for team USA. As a female-to-male, Mosier needs to take testosterone, though a Therapeutic Use Exemption means it's acceptable. The Wikipedia article states that "two closeted transgender athletes competed" at Rio.

The first transgendered sportsperson I recall ever hearing about was Mianne Bagger, a professional golfer from Denmark. According to Wikipedia, Bagger was only the second high-profile transgendered athlete who won recognition from sports' governing bodies to compete in their desired sex, after Renee Richards. A 2004 article from the Guardian newspaper reports that Bagger experienced a slightly warmer welcome from her fellow professionals than Richards did. Subsequently, Lana Lawless sued the Ladies' Professional Golf Association in 2010, which at that time was clinging to a rule that women golfers were required to have been born female. In 2014 another doctor, Bobbi Lancaster, was permitted to play in an LPGA tournament, and this article describes her as the first transgender woman golfer to compete in such a tournament.

So much for the professional athletes. What about those lower down? Una over at TransasCity has produced a couple of relevant articles, and you can read them here and here.

Judit Polgar

I want to close this double article with a shout out to one of my heroes, Judit Polgar. Polgar, 40, is the strongest female chess player in history. The youngest of three sisters, the Polgar girls were intensively coached in chess by their polymath father, Laszlo Polgar, who believed that "geniuses are made, not born".

Everybody "knows" girls aren't as good at chess as boys. Even FIDE, the world chess governing body, awards separate women's titles. The Woman Grandmaster (WGM) title is easier to attain than the Grandmaster (GM) title. But try telling that to the Polgar sisters. They refused to compete in woman-only tournaments, from the beginning, bringing them into some conflict with the Hungarian Chess Federation. However, the Polgars persisted. Laszlo wrote:

Laszlo Polgar: Women are able to achieve results similar, in fields of intellectual activities, to that of men. Chess is a form of intellectual activity, so this applies to chess. Accordingly, we reject any kind of discrimination in this respect.

And his daughters went on to prove him right. Judit achieved an astonishing series of accomplishments: she achieved the rank of full Grandmaster (not WGM) at the age of 15, then the youngest person ever to have done so. She was ranked 55th best player in the world at age 12. She is the first ever (and so far, only) woman to achieve an Elo rating of greater than 2700, and she peaked at number 8 in the world in 2005. Now, of course, FIDE allows players of both sexes to compete in tournaments, but of 1441 GMs in the world, only 31 are currently women, so the women do have some catching up to do. And I bet nobody even bothers about their testosterone levels.

I wonder how much chess is like golf. In most Olympic sports, muscle mass, lung capacity and other physical measures of fitness really matter. In that circumstance, one could say that the extra physical size of someone born male could offer an advantage if they transitioned. However, in golf, this is less obvious, and Mianne Bagger has insisted that she has no physical advantage from being born male.

In chess, of course, physical fitness is irrelevant, provided you can deal with the stress of the games and tournaments. I believe that the low number of female grandmasters is not a reflection of women's ability to play chess, but a reflection of how few women take up chess seriously. I did a quick Google search for transgender chess players, but didn't turn anything up. As always, comments are welcome. Meanwhile, whether it's golf, chess, cycling or whatever, keep doing your thing.

A Tale of Two Boxes

Back in 2014 I wrote a post called Frightening the Horses, which largely discussed a 2002 article by American writer and psychotherapist Amy Bloom, entitled Conservative Men in Conservative Dresses, which was published in Atlantic Monthly.

The first line of the article is this one:

Bloom: Heterosexual cross-dressers bother almost everyone.

When I first read that line, I found myself agreeing with it. In fact, some of them even bother me, and I am one! If you missed Bloom's article, it's well worth a read in its entirety. I think it's also worth having a read of my post; it certainly generated a lot of discussion.

I've been thinking about why it is that crossdressing bothers us so much. As Bloom says, drag queens don't bother us. Nor do female impersonators (she cites several American examples; instead I point you to Danny la Rue, and Hinge and Bracket as popular British examples). She even points to those women in history who have had to adopt the male persona in order to succeed. And transsexuals don't bother us.

I don't speak his language

I cross-dress whenever I can, which is not as often as I would like. The rest of the time I live my life as if I were an ordinary man.

But my whole life I have been different from other boys and men. I am sensitive. I cry easily. I loathe many of the trappings of “traditional” masculinity (field sports, big rugged vehicles, hunting and fishing, weapons, coarse behaviour, macho posturing, or the objectification of women). I especially loathe it when other people (men or women) ascribe those things to me, or assume I must have some affinity with them, just because I was born a boy.

You might say that I should just learn to be a sensitive man and to find ways to explore and express my sensitive, caring, nurturing side in the world of men (and stick two fingers up to the knuckle-dragging bottom-feeders who would persecute me for it). But I don't: instead I choose to express those aspects of myself by attempting to experience the world of women. It's not just the clothes and the lipstick: those are merely the external manifestations of something which goes right down to my core identity as a human being. I feel much more comfortable in the company of women. I espouse feminist principles very openly. I suspect (but cannot, of course, be sure) that I have been imprinted (at a young age) to associate femininity with the aspects of my personality I cannot easily express as a man. In other words, it’s too late to change.

“Crossdressing makes you comfortable,” I am sometimes told. No. Slippers make me comfortable. Crossdressing (using that as a convenient shortcut for the whole package of stepping out of the male role and embracing the female one) is a necessity for my psychological wellbeing.

So it's a simplification (and a hurtful one) to say I just “like to dress up” or “it's all just a bit of fun”, or I am just “getting in touch with my feminine side”. It goes much deeper than that. I have powerful and irrepressible yearnings to dress, and when I do, it feels right on a level which is difficult to fully articulate. It isn't an act. It isn't a pretence. It doesn't feel like a sham.


Kept apart: male and female

I can see why some people need that feeling all the time. In other words, I think what separates me from them is not some huge gulf (“a cross dresser is only pretending to be a woman, while a trans woman is a woman”), but actually a considerable degree of overlap.

I have found that suggesting this makes some trans women uncomfortable: men who cross-dress in our society (and don't I know it!) are treated as figures of scorn or ridicule (or worse, sexual perversity), and I can completely see why trans women would want to distance themselves from that. But from my perspective, it is the truth.

As a male-to-female crossdresser, I do feel that some fully-transitioned people look down on me. They seem to be saying "We are nothing alike, since you are 'only' a crossdresser. Our motivations are not the same. Our behaviour is not the same. The reasons why we do what we do are not the same".

The difficulty I have is that none of these things is demonstrably true (and I admit I am a lumper, not a splitter). When I ask those people to explain their viewpoint (or occasionally challenge them) I get three basic responses:

1. Because I don't automatically accept their word, I must be transphobic, just like all those others.
2. I haven't done enough reading, and if only I would read this book or that blog it would all become clear; or
3. I can't possibly understand because I am "only" a crossdresser.

I stress that these people are the minority, and that most trans people I know are lovely, welcoming and inclusive.

The story we tell ourselves

But here is what I think: society has a story we tell ourselves. That story is that there are two genders, male and female. The most "acceptable" people are those who start off on one side and stay there. But most people are (I think) comfortable with people who start off on one side and go all the way across to the other, because that just about fits the story.

I think it’s easier for cisgendered people to accept a person who “was” once a man but “is” now a woman, and it’s harder for them to accept that, actually, there are a lot of us somewhere in the middle zone (perhaps the rainbow zone?) between those two boxes (including some people who might identify or “qualify” as cis-gendered). (Likewise, it's acceptable to be a drag queen, who is male in his normal life. Putting on a dress is only an act, right?)

But society is very uncomfortable with people in that middle zone, because they don't fit the story: it might be people who choose to be neither one nor the other gender, intersex people, or people (like me) who trespass across the middle zone from time to time. (I think that explains why there is tremendous pressure on intersex people to align themselves to one or other gender).

Which one do you think I am?

Of course, the story is wrong, at all levels from the cell, to the person, to society as a whole. But that is still the story we tell; even some trans people tell it. I think a lot of trans people overtly, or subconsciously, reinforce that gender binary. I think it helps them to feel more comfortable about themselves, and I think it helps cisgendered people to feel more comfortable about them.

I don’t identify as an ordinary man. I don’t identify as a woman either. I am not quite sure what I identify with! I sometimes describe myself on Quora as a "part-time woman". And I want to say to those people who think they are so different: we have more that unites us than divides us, and we should concentrate on our commonalities, not our differences.

As for the stereotypes of men and women, they are created by society. But I am a member of society. I cannot simply step aside from its conventions, nor ignore its rules (whether they please me or not). Even though there are many, many people who don't fit the stereotypes, the stereotypes persist. It does seem, though, that society is changing: it is becoming more acceptable to not fit the binary.

Come and join me in the middle zone. There are plenty of comfortable seats, and the wine has just been opened!

===
Addendum 28th August 2016

My thanks to Patricia for sending me a link to this article by Rebecca Reilly-Cooper. It's articulate, forthright and powerful, and adds another perspective to the idea of the "spectrum of gender" You can read the full thing here.

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.

Abigail Austen

If you could look at my hit counter, you would see that one of the most popular blog posts I ever wrote was the one concerning Jan Hamilton, the elite British soldier who underwent transition and was firmly in the public eye a few years ago. The documentary Sex Change Soldier, followed her journey through transition, and every time it airs somewhere around the world, I get a bump in the hit counter as people get online to try to find out the latest. But there hasn't been any for years.

You can also see (from the comments under that post) that lots of people are interested in making contact with Jan, and I even went so far as to contact the producers of the documentary to ask if they could put me in touch. Nothing.

Abigail Austen

Then, out of the blue last week I got an email from Jan herself-- except she isn't Jan, she is Abigail Austen ("Abi"). I knew that already, of course, but I hadn't published that info on my blog because I believed that Austen was trying to move on with her life and try to find some anonymity.

But since she got in touch, I couldn't pass up the opportunity to interview her, and she agreed. It turns out there is a lot to tell. As always, I was a bit nervous about what questions to ask: I have never before interviewed someone who has been thoroughly trained to resist the most probing of interrogations! Here is how we got on:

It's been 8 years since the documentary about your transition. Can you tell us briefly what's been happening in your life since then?

I decided to quietly get my life into order, away from what had become a very intrusive press. It got so bad, I had to move out of my home for a bit. Journalists were hiding out in my garden!

The Scottish Police were looking for people, so I joined there for a few years. I enjoyed being a cop, but my profile made it difficult to avoid a fight. I was causing more aggravated assaults by myself than the rest of my division put together, merely for being me.

After three years, I was offered a job with NATO in Afghanistan. I went to Kandahar with the US Army, right into the heartland of the Taliban. I stayed on combat operations continuously for three years, coming home late 2014. After that, I took some much-needed time off and wrote a book about it all, called Lord Roberts’ Valet. Then, I took off for the Ukraine, where I work in security operations.

Can you tell us why you changed your name to Abi Austen? Was that an attempt to become anonymous again after the negative publicity associated with the name Jan Hamilton?

No, it was because my family rejected me. I didn’t want that name anymore. My grandmother was an Austin, and I loved her very much, so I went with that, and added a little Jane Austen twist to the spelling.

You briefly pursued a career as a police officer. How did that pan out?

Mentioned a bit about that above. The senior management were supportive of me, but it was a hard gig with some of my fellow officers. I had a publicised spat with them over the pension fund when they insisted in enrolling me as a man, which I am patently not. By the end, it was all becoming waaay too stressful… So I swapped it out for going back to war!

After how badly the military treated you, it must have been very difficult to return to a career in the armed forces, however tangential. What made you decide to return?

I have always found military service enjoyable, rewarding and exciting. So it actually wasn’t that hard. I love Afghanistan. I’ve travelled there for over twenty years. The offer from NATO was a real opportunity to put my life into order, and it all came good. It’s all in the book. My move back to Afghanistan was as much because I wanted to go back there (I do love the place) as any desire to work with the military. I am not some sort of military nut. Far from it. In fact, the book is quite scathing about military culture

What sort of reaction did you have from your colleagues when you returned to the military? Were they accepting? Or is there still an undercurrent of transphobia?

Back to the action: Austen

Well, I didn’t arrive with a rep where the Americans were concerned. They just saw me as another chick: and I had skills they wanted. So the Yanks were just great. I really owe the United States. They are a country of second chances, and they really helped me change my life about. Kandahar turned into one of the great adventures of my life and I will always admire and respect America for the sacrifice they make for all our freedoms.

You worked for the US military, not the British. Is this because they were more accepting of you, or because you didn't want to work for the Brits, or some other reason?

There were some Brit special forces in Kandahar. Reaction was mixed, which reflects society. I don’t really stand out in any way, I’m just a chick, but some of them obviously knew who I am from all the media stuff in the UK. For people under 30, nobody really cared. In fact, many of the young ones wanted their picture taken with me. Over 30, and it was more mixed. The army is a big ball of testosterone and men somehow feel threatened by people like me. I don’t know why, but it can be difficult sometimes.

Do you think attitudes to transgender people in the military are changing? In what way?

The military are a reflection of the society they represent. However, it is also a conservative organisation, so attitudes lag. The military is beginning to understand that gender dysphoria is a medical, not a psycho-sexual issue, so they are beginning to discuss it in adult terms. However, I think it will be a generation before gender is openly discussed in wider society, and the military will always be behind that curve of popular opinion because of its own internal culture.

Do you think the changes have something to do with you personally?

In my own small way, I think I have helped change attitudes. However, there are others out there who have fought the good fight. I’m about to take part in an exhibition here in the UK, on transgendered service personnel, called Dry Your Eyes, Princess, which will tour Liverpool, Belfast and Manchester. I did a three-hour taped interview for that exhibition which covers many of the details of my life.

I do know that the US is currently lifting their own ban, and my example in serving in Kandahar helped alter concerns on operational robustness. I met several very senior officers and politicians on that very subject. But I’d also say, I regard that part of my life as something from the past. These days, I am just a chick.

Now you have a book out. Can you tell us a bit about it?

Got it covered: the book

Lord Roberts’ Valet is the story of my 1,000 days in Kandahar, at the eye of the storm. It’s the inside track on how the war was fought and all the mess-ups we made over there. I experienced everything from the frontline, to the politics of the White House: and it’s all there in the book. The historic context, the story of the war, the sacrifice, the tears, the laughter and the madness. I genuinely don’t think there’s been a book quite like this before on Afghanistan and I’m quite proud of it. There’s a fair amount on the web now on it. Check out the website here:  http://www.lordrobertsvalet.com

Did Kristin Beck's book Warrior Princess have anything to do with your decision to write it?

Kristin Beck? Nope, good luck to her, but this is a different story.

How did you choose the title?

Lord Roberts’ Valet is about my war and the war the West fought. The story behind the title is in the book, so I won’t spoil it. I have a follow-up coming out later this year called Sugar and Spice, which will chronicle my own journey to where I am now.

What are your next plans? More armed conflict? Or have you something else in mind?

I’d like to think I have one more mission in me. My time in Kandahar proved to me that my skills are just as sharp as ever, no matter what physical form I live in. I also know that being me has made me a much happier and better person to be around. I have never regretted a single day of my life as Abi. I have a few irons in the fire right now, but I’ll hang onto those dreams for now...

You've been "stealth" for years; what made you decide to re-emerge?

I don’t like that term. I just call this living life. I’m proud of all that I am and all I have achieved. I’ve never hidden away at all. Right now, I have a book (and soon two) that I think worthy of a read and I’m just doing what any author would do: telling folks about what’s on offer. I’ve never hidden away. If anybody wanted to speak to me, I’ve been there; and, over the years, I have talked to and helped many people on their own particular journeys. That part of life will always be with me, but I regard the ‘trans’ part as ‘transformation’ and ‘transitory’. It’s history, nothing more. I am a female, and a very happy one too. There comes a point where you don’t need to fight anymore, and I am at that point.

Can you tell us a little about your personal life these days? A relationship?

Yep, very happily in love. My partner and I have a lovely life and we intend getting married quite soon. It’s all good….

What interests or hobbies do you have?

Love Zumba, I actually have an instructor’s certificate in it. And I still go running, but I’m not really made for sprinting these days.

What famous person would you most like to meet and why?


Not all fighting: Afghanistan

To be honest, I’ve met an awful lot of famous people already. Some I’ve liked, some I have wondered what all the fuss was about. I don’t judge people on their fame. I just like genuine people for themselves. So; happy to meet anybody, they don’t have to be famous, just real people.

Do you have a message for people out there who have been thinking about you?

I’d like to say ‘thank-you’ to everybody who has written to me and sent good wishes through the years. My documentary is still in rotation around the world and I get notes from the most unlikely places. I think that there are a lot more folks affected by this issue than have ever been able to express their true selves. I wish everybody true happiness and love. I’ve been on my own particular road. If my own experience is any use, I know it can have a very happy ending.

I will be on Lorraine Kelly’s ITV show on 05 November, here in the UK. Could you also mention that I have a Facebook page and a YouTube video will be up this week. All folks have to do is Google "Lord Roberts’ Valet".

===

As with all my interviews, a little discussion and analysis now follows.

First, I admit I was concerned about Austen. Having heard nothing about her life, I naturally assumed that she had fallen into obscurity and perhaps misery. And let's face it, the documentary doesn't exactly end on a high note. So I was delighted to hear that she is not only doing OK, she is actually doing brilliantly. My first emailed question to her was: I just want to know you are OK.

Second, I was intrigued to find that she had gone back to working with the military. On the one hand, this must have been a tough decision. The military treated her extremely badly at the time of transition, and it must have been very painful to consider returning. And yet, by her own admission, she loves what she does. She is extremely highly trained, and has a lot of valuable experience to draw upon. And, from the excerpt from the book (available on the website) it's clear she has lost none of that traditional coolness under pressure.

As I have mentioned elsewhere on this blog, I view the military with very mixed feelings. On the one hand, I admire the job they do. On the other, I find most military types to be intimidating, and I find their rigidity and inflexibility of thought to be stifling at times. But I can imagine that, if the military is your thing, you might find nothing in civilian life quite hits the spot. And the opportunity to do that thing, the thing you are trained for and love most of all, while being accepted as your true self, must be a very powerful experience. The press-release for the book contains this quote from an unnamed senior US general:

I don’t care if you are a man, woman, Martian or dachshund. My only question is whether you can do the job required or not. Welcome to the team.

Third, I'm a little surprised at one particular word which Austen uses more than once: chick. It doesn't quite fit for someone who is so trained and so capable, to refer to herself as "just a chick". It's not a word that I personally would feel comfortable applying to any woman, whether I myself was presenting as a woman or a man. Likewise, if someone applied it to Vivienne, it would make me bristle slightly because of its connotations of sexism. So why does Austen use it in reference to herself?

Fourth, I came away from this interview feeling that, while Austen has told us a lot about her career, she has told us surprisingly little about herself. This tone also comes across in our email exchange. My questions were intended for the reader to get a sense of Abi the woman, Abi the person, and yet she gives us little to go on: very brief details about her grandmother, her partner, Zumba, and some hints of "irons in the fire". That makes it very hard to get any sense of Austen's real personality. I guess she might say: read the book!

I can understand why Austen may feel a little bit reluctant to let too much slip. I suppose it would be easy for some tabloid journalist, hungry for a story, to take some little detail out of context, and blow it up into an article to fill up some column inches. So I am not blaming her for her reticence, just a little disappointed. I suppose I had hoped that we (she and I) might click a little over some common ground. That may yet happen.

Meanwhile, I await the Sugar and Spice memoir with some anticipation, and I will be sure to let you know if I hear of anything.

===

My thanks to Abi for taking time to answer my questions and send me her photos. The website again is here. The contents of this post are copyright © Vivienne Marcus and Abigail Austen 2015. No reproduction of any part of the text is permitted, altered or unaltered, in printed or electronic form, without permission. All photographs are copyright © Abigail Austen and used by kind permission.

Galileo's Middle Finger - Part Two

This is the second of my articles discussing the book Galileo's Middle Finger, by Alice Dreger. If you haven't already, it makes sense to start reading at Part One, which discusses intersex individuals.

Dreger: When people ask me how transgender is different from intersex, I usually start by saying that that intersex and transgender people have historically suffered from the opposite problems for the same reason. Whereas intersex people have historically been subjected to sex "normalizing" hormones and surgeries they have not wanted, transgender people have had a hard time getting the sex-change hormones and surgeries they have wanted. Both problems arise from a single cause: a heterosexist medical establishment determined to retain control over who gets to be what sex.

Manly: legs

Here she is, shortly into chapter 2, Rabbit Holes, and characteristically getting right down to the nub of the issue. (For my own, similar take on intersex vs transgender, I refer you to this post, though you might need to scroll down a bit).

Dreger: In the great majority of cases, medical scans won't detect any intersex feature in a transgendered person's body. Nevertheless, many people believe that transgender must be a special form of intersex involving the brain.

This fits with my comment that some transgender individuals look to the existence of intersex individuals to provide justification for their behaviour.

Dreger: Although there is very little science to support it, this has become the most popular explanation of transgender, probably in part because it is the easiest one for uptight heterosexuals to accept. (...) In practice, this story of transgender can function as a kind of get-out-of-male free card for men who seek to become women anatomically. When that card is played, the comforting narrative of "true selves" is preserved.

And there are scientific papers (such as this one) which seek to demonstrate anatomical differences in the brains of trans people. Though mostly their brains are very similar, some studies purport to demonstrate subtle differences in tiny regions of the brain (for example, some regions in MtF transsexuals are less like men and more like women). Most of these studies have small numbers of non-randomised participants, and even if these findings are robust (and I am nowhere near convinced that they are), correlation is not causation.

Science may indeed unlock some of these puzzles in time, but the only thing I am convinced of is that the science is pretty unconvincing so far.

Controversial: Bailey

It's at this point in the narrative that Dreger introduces Professor J. Michael Bailey, the author of the controversial work The Man Who Would Be Queen: The Science of Gender-Bending and Transsexualism, published in 2003. Bailey drew on the work of Ray Blanchard, and is therefore supportive of the autogynephilia model, to which I subscribe, as you probably already know. See here for a fuller discussion of this model. In that link, I also discuss how the autogynephilia model makes me feel uncomfortable about myself, because it insists the root of my crossdressing is in sexual desire.

Dreger points out that the French translation of autogynephilia is amour de soi en femme (love of oneself as a woman) which is a much nicer expression.

But where I feel uncomfortable about the autogynephilia model, a lot of people felt a lot worse.

Dreger: Before Bailey, many trans advocates had spent a long time working to desexualize and depathologize their public representations in an effort to reduce stigma, improve access to care, and establish basic human rights for trans people. (...) This is similar to how gay rights advocates have desexualized homosexuality in the quest for marriage rights, portraying themselves in living rooms and kitchens instead of bedrooms, in order to calm fearful heterosexuals.

Indeed, a few retrograde clinicians, like Paul McHugh, a psychiatrist at the Johns Hopkins School of Medicine, still actively use the idea that male-to-female transgender is really about perverted sexuality and mental illness to argue against access to sex-transitional hormones and surgeries.

For Bailey or anyone else to call someone with amour de soi en femme an autogynephile or even a transgender woman-- rather than simply a woman-- is at some level to interfere with her core sexual desire. Such naming also risks questioning her core self-identity in a way that calling the average gay man homosexual simply can't. One really must understand this if one is going to understand why some trans women came after Bailey so hard for naming and describing autogynephilia. When they felt that Bailey was fundamentally threatening their selves and their social identities as women-- well, it's because he was. That's what talking openly about autogynephilia necessarily does.

Lynn Conway by Charles Rogers

It's worth digressing here to make a couple of remarks. Just because a scientific theory makes you uncomfortable, doesn't make it wrong. And just because you insist upon something, doesn't make it right. If you want to convince me, you need to do a lot better than insist. I respond to evidence, not vehemence. This has occasionally caused me to get into uncomfortable debates with other trans people when I dare to question them about their views and beliefs. Sometimes, when they are unable to explain themselves, they resort to some variant of: "Of course, you couldn't possibly understand. You're only a crossdresser, where I am a woman".

But back to the book. Dreger goes on to describe how a prominent transwoman called Lynn Conway, at the University of Michigan, started "what became a war" against Bailey, assisted by Andrea James and Deirdre McLoskey. Together they began to systematically ruin Bailey's reputation. They campaigned to have the book removed from consideration for the 2004 Lambda Literary Award. They cooked up stories about him practising psychology without a licence, doing research without appropriate ethical oversight, and even having sex with one of his research subjects. And Dreger digs deeply and thoroughly into all of this, interviewing as many of the original people involved as possible.

Dreger: As a result of all this, Bailey came across pretty clearly as an abuser, a trans-basher, and a sexual pervert.

After nearly a year of research, I could come to only one conclusion: the whole thing was a sham. Bailey's sworn enemies had used every clever trick in the book-- juxtaposing events in misleading ways, ignoring contrary evidence, working the rhetoric, and using anonymity whenever convenient, to make it look as though virtually every trans woman represented in Bailey's book had felt abused by him and had filed a charge.

But why did Conway, James and McLoskey feel they had to do all those things?

Dreger: "Narcissistic injury," the physician-researcher Anne Lawrence said to me, by way of explanation. "Followed by narcissistic rage." That, she told me, was the only real way to explain what happened to Bailey. The whole thing had been an attempt to kill the messenger bringing a message that Lawrence guessed wounded the accusers' sense of self.

Captivating: the book

By this point, we are barely a third of the way through the book. Several things stand out. First, the book is extremely readable, and the narrative is told in a personal, conversational style. Second, Dreger's scholarship is impeccable: many hundreds of hours of interviews and research have gone into this book (you should see the references), and Dreger seems uncompromising in her search for the truth. Third, it's clear that a great deal of her personal energy has been invested, not just in writing the book, but in sympathising with the people in it, befriending them and becoming part of their lives. Fourth, writing this book has taken considerable courage, and Dreger has herself come under fire, risking her own career and reputation (drawing parallels with Galileo, of course).

Overall, the book is a phenomenal read; gripping as a thriller, scholarly, yet incredibly human. There are so many points in the book where I thought: I can't believe I am actually reading this! I can't recommend it highly enough.

We part company with the book at this point, partly because this blog post is already way too long, and partly because the book leaves the subjects of gender and sex as Dreger finds other (compelling) subjects to sink her hungry scholastic teeth into.

I think the world of gender is changing more rapidly than it ever has before. The emergence of transgender celebrities like Laverne Cox and Caitlyn Jenner has caused mainstream society to become much more aware (and thankfully, accepting) of trans people and trans issues. Nonetheless, I am very uncomfortable about what happened to Bailey: vilified for his views, not because they were wrong, but because they made people uncomfortable. Dreger points out (and I don't know why I didn't think of this before) that as a result of Conway's attack on Bailey, "no one in sex research will touch male-to-female transsexualism with a ten foot pole any more. Which must have been just what Conway meant to do". That explains why there isn't good science: because scientists fear personal retribution if they publish results which are unpopular.

The way to enlightenment is not to silence people, even the ones who disagree with us, but to engage in open, civil, respectful debate; to seek out the best evidence, and incorporate it into the picture, recognising that the picture isn't complete and may yet change as new discoveries come to light.

Dreger's book has inspired me to be a little more upright, a little more outspoken in defence of the truth, a little more questioning of the "facts", than I was previously. And perhaps, therefore, a little more willing to extend my middle finger, just like Galileo.

Caitlyn Jenner

No doubt anyone in the world with access to a television has become aware of Caitlyn Jenner (whether they like it or not).

Born William Bruce Jenner in 1949, and known as Bruce Jenner for many years, Jenner (now 65) is probably the most famous openly transsexual person in the world. Jenner was an Olympic athlete, winning the gold medal at the Men's Decathlon in Montreal. Earlier this year, Jenner publicly came out as a transwoman, changed her name to Caitlyn and underwent a highly publicised transition (although there had been some signs for a long time). I dare say she will figure prominently in the reality TV schedules for some years to come. (And, no doubt, the wearisome jokes and mockery will continue for a while longer).

Trying to be Bruce

But you already know all this. Why am I troubling to write about it?

Lately I've spent quite a lot of time reading and writing on Quora. It's a wonderful website for people like me, who are curious about all sorts of things, and have an opinion (and occasionally some pertinent knowledge) about all sorts of things. (You can find my Quora content here). Although I have added links to Quora content throughout this article, I am not sure if you will be able to access them all without registering to the website.

Someone posted this question:

What is the appropriate name and pronoun to use when talking about things that Caitlyn Jenner did in the past, while she was known as Bruce and thought to be a man? 

That really got me thinking. Who won that gold medal?

From one point of view, it's pragmatic to say that the winner of the medal was Bruce Jenner. The competition was the Men's Decathlon. Therefore the correct pronoun to use is "he"; he won the medal. On the other hand, Jenner herself says she struggled with gender dysphoria her whole life, even when competing and winning that medal. And now the person who won the medal is Caitlyn Jenner, and takes female pronouns. Therefore she won the medal.

Call me Caitlyn

There was a reasonable amount of discussion in the responses to the question. As one might expect, some people felt quite strongly about the matter.

Tessa Norris writes:

The correct way to refer to a transitioned trans woman is to refer to her with her current name and pronouns, and to abandon her old name and pronouns.

Tamara Wiens writes:

Referring to a trans person by their "dead name" is usually taken to be very offensive. Personally, it's bothersome in an ill-defined way - when anyone says it, it makes my skin crawl, and I want to be ill, so it's fortunate that it is happening less and less all the time.

Katie Anne Holton writes:

My preference is that no one use my former name, ever.

Whatever I did under another name, I did it. Katie was born in 1963. Katie married in 1990 and divorced in 2006. Katie fathered two beautiful children.

In the same sense, Caitlin Jenner was an Olympic athlete. She won a gold medal in the decathlon. She got married. She fathered children.

I disagree with Tessa Norris. There isn't, as yet, a "correct way". There is only a society struggling to agree on a way to get a linguistic handle on what is, for many people, a comparatively new phenomenon. I accept there are ways that some people would prefer over other ways, but that isn't the same thing as a "correct way".

I must say I had never heard of the term dead name or deadname before this discussion, and it struck me as a term laden with powerful connotations. It reminded me of the notion that in mediaeval times, a "funeral" service would be held for novice nuns and monks on entering their religious community, to symbolise their "death" to society; that the person who had previously lived was now gone. I don't really know how often this actually happened, but it seems terribly barbaric.

More from Vanity Fair

I can understand Katie Anne Holton's perspective. Nonetheless, it makes me a bit uncomfortable. When Bruce Jenner competed in the Olympics, everyone thought he was a man. He presented externally as a man (regardless of his inner feelings). All the documentation at the time used male pronouns. (In fact, even in the recent Bruce Jenner Interview With Diane Sawyer, Bruce agreed to be called Bruce and asked for masculine pronouns to be used even though transition was already underway).

Then there came a change, which was initiated by Bruce himself. He has asserted a new identity and changed his name. I think that we should now respect Caitlyn's new name and identity, but for me this doesn't apply retrospectively.

One's innate preferences and choices do not, in my opinion, compel the rest of society to rewrite the past. (And by preferences, I don't mean that gender is a preference, but I do consider that how people act and present is a preference and a choice. I think that Bruce was choosing at that time to try to be Bruce, even though that was difficult and painful).

I tried to take the discussion further, but the fact that I somewhat disagreed was met with some hostility at first:

Tessa Norris: You have the "right" to refer to my past against my express wishes in any way you choose. But only in the sense that you have the free speech right to call me a "tranny faggot" if you want.

Then came an answer by Elliott Mason, which I think was extremely pertinent:

How would you refer to the sports accomplishments of Muhammad Ali before he changed his name? It's an interesting parallel case to think about, because at the time his change was just as shocking and just as much of a media circus as Ms. Jenner's name change is now.

Also, very many female Olympians have married and changed their last names after their athletic careers are over. I don't think I've ever seen anyone make a big deal about using their maiden name to refer to their accomplishments in their former athletic career. One mention near the top, at most, and the rest of the article in their current name.

It certainly seems right to compare Muhammad Ali and Caitlyn Jenner, although Ali's name change came before much of his sporting success. I am not aware of any situation where Ali would be referred to by the name Cassius Clay, except in articles which say something like "Muhammad Ali (born Cassius Clay)".

What could they make me look like?

Elliott goes on:

Would you apply the same rule in the same way for people who changed their name for any other reason? When referring to childhood accomplishments of, for example, movie stars who use a screen name (Cary Grant, Audrey Hepburn, Queen Latifah, and Judy Garland come to mind), do you insist on always pointing out their old name and saying that they changed it?

If you do not, then the only reason for a difference in how you treat them and Ms. Jenner is that you have some issue about her name change that you don't have about theirs, and you should think about that.

My response to this is much easier. All those names are stage names. A stage name is deliberately chosen for its attractive or unique qualities. A stage name is something one adopts for a stage persona, not a personal identity.

Do Olympic stars have their names engraved on their gold medals? I don't know. But suppose they do. Will Caitlyn Jenner have hers changed? I think probably not. To me it would seem as ridiculous as Laurence Tureau having his junior school Bronze Swimming Certificate changed to the name of Mr. T.

But I guess my final point is this. I can only comment from my own perspective. I don't consider myself to be a woman. I prefer to be treated as one when I am presenting as fem, but I regard this as a privilege which I need to merit, not a right.

Right now, I am not sure about what the future holds. Maybe I will transition at some point (say Jenner's age) and maybe not. Suppose I do, I would be quite happy to acknowledge my former identity; in fact, I quite like it (my current identity), which might be one reason why I don't feel I need to transition.

I don't see, if you could compare me to Jenner at an equivalent age, that there would be much difference between us. I have tried to suppress my feminine side; I have struggled (and still am) to find some balance.

And yet, I don't consider myself to be a woman, though I certainly don't consider myself to be an "ordinary" man either. I can understand how trans people might feel uncomfortable about their previous lives, but nonetheless those lives existed, objectively, sometimes for decades.

I would argue that one should respect an individual's choice of name and gender presentation. To me this is a facet of basic human understanding, tolerance and compassion. On the other hand, I don't think it's OK for an individual to insist that the past be rewritten just because its existence makes them uncomfortable.

As always, this is an ongoing discussion, to which your contributions would be welcomed.