Gender Transition: The Moral Meaning of Bodily and Social Presentation

Abstract

Medical and/or social gender transition need not involve denial of one's biological sex, but raises other taxing ethical issues. These range from sexual ethics issues narrowly understood to consideration of the claims of any spouse or children and indeed, of gender-discordant younger people who may follow one's example. As with intersex conditions, not all crossdressing or use of cross-sex hormones is excluded absolutely. Detransition, for example, could be rightly deferred for various reasons. However, as illustrated by the analogy of an infertile woman wanting to present as the pregnant mother of a child she plans to adopt, there is a significant social value in accurate bodily and other outward communication of one's actual/predominant sex (and occupancy of key allied roles).

‘Transgender’ is an umbrella term (one might say, a label¹) describing a mismatch between one's personal sense of being male or female,² and one's birth sex and associated social gender which feel alien, at least to some degree. ‘Gender dysphoria’ refers to unease or distress at one's sexed body and/or social gender³ and the discordance between this body/social gender and how one identifies internally.

It should be stressed that those who have transitioned medically will often not believe they are now, or have ever been, full biological members of the ‘target’ sex – as opposed to believing they now function for some/many purposes like members of that sex (and the associated gender). Transitioned people who may believe they have a form of intersex condition (the ‘brain sex’ model) may still accept that, like the vast majority of intersex people, they were born with a predominant biological sex which medical transition cannot change. That biological sex may indeed be acknowledged by the person as a persisting source of pain or unease. While the moral significance of a person's biological sex is something on which there is, of course, widespread disagreement, the fact of the biological sex – no less than the fact that the person feels alienated from that sex and/or the associated gender – need not be a matter of dispute.

Adoption analogy

The question then is: assuming that the person has a certain biological sex, and experiences a strong tendency to identify with the opposite sex and gender, what is the best way forward morally, in the first place for the person, but also for those around him or her?

In approaching the question whether medical and/or social transition might be morally right for oneself or another adult, the analogy has been given of adoption as something based on a biological reality – the relationship of genetic-cum-social parenthood – but which does not require any deception or illusion on the part of the adoptive parent. An adoptive mother, for example, while she is not the biological mother of her child – a fact she may have no wish to deny – is indeed a genuine mother of the child, and should not be otherwise described. It would be incorrect, as well as ill-mannered, to call her a ‘non-parent’, since for most practical purposes she is no less a parent than a genetic and/or gestational mother. In the same way (it is claimed) while there is a conceptual connection between the gender with which one identifies and the biological sex associated with that gender, for most or many purposes one can truthfully identify with the gender even in the absence of the associated biological sex.

This analogy, which has been made recently in this journal,⁴ is ingenious but not, I believe, sufficiently close to the case of gender transition to be ultimately convincing. I will adapt the analogy below in a way I believe helps illustrate what I see as a strong moral onus against social transition, let alone transition via surgery and/or hormones.

Moral absolute or moral onus?

I should say at the outset that in making this case, I have absolutely no wish to deny the painful and debilitating nature of gender dysphoria for the real-world people who experience it through no choice of their own. The intense politicisation of this area and growing marginalisation of responses other than transition only make more acute the need to address carefully the individual situations of those affected by dysphoria. Nor do I wish to suggest – however troubling the powerful social forces favouring transition – that it is intrinsically wrong in all cases for someone, including someone with dysphoria, to dress in the clothes of the gender associated with the opposite sex, or even indeed to take cross-sex hormones.

After all, in considering these questions, we need to remember the situation of ‘intersex’ people as the term is normally understood ie those born with a disorder of sex development (DSD)⁵ who, if raised in the opposite gender, may find it very difficult, at least in the short term, to transition to the gender associated with their true (predominant) biological sex. That biological sex may, after all, be a recent surprise for them: perhaps something only revealed when they go through a kind of puberty which they were not at all expecting. Intersex people are not the main subject of this paper, but do share some of the same dilemmas regarding identification or non-identification with one's biological sex and the associated social gender, including the choice to use or not use cross-sex hormones. While people with DSDs often have no desire to transition from the social gender in which they were raised, their own situation also raises questions regarding gender presentation, including to potential sexual/romantic partners, if such presentation does not accord with their predominant biological sex.

Returning to the main subject of this article: it is also helpful in exploring these issues to consider the case of a person who has already transitioned away from the gender associated with their biological sex as a means of dealing with dysphoria. Such a person, like the person with a DSD, may or may not be in a position immediately to transition (in this case, back) to the relevant gender, and away from a current gender not associated with their biological sex. Inspired perhaps by the growing numbers of detransitioned people sharing their experiences, some transitioned people may be seriously drawn to detransition but may nonetheless need to delay beginning or at least, slow down the pace of detransition for one or other practical reason. Clothes may need to be bought first, cross-sex hormones may need to be stepped down gradually to make this a better experience and/or detransitioning may need to be deferred until the person feels sufficiently confident and mentally prepared. Even if the person is in fairly good health mentally, and is confident about the general decision to detransition, a recent traumatic life event such as a bereavement might reasonably cause the person to delay detransitioning until a more opportune time.

Admittedly, for some, there may be specific sexual ethical reasons in favour of more urgent detransition: we might think of those wanting to avoid sexual involvement with (or fantasies concerning) same-sex partners or to avoid crossdressing with a self-directed sexual/romantic motive of the kind to which, controversially, some trans-identifying people testify.⁶ In many other cases, however, it does not seem that, morally speaking, even if the person should eventually detransition, this absolutely needs to happen now. Even less does it seem that someone who is detransitioning gradually as regards dress and/or use of hormones is doing wrong by doing this in stages.

Nonetheless, I will argue that there is, at very least, a moral onus against continued crossdressing and use of cross-sex hormones even for motives apart from sexual/romantic motives of any kind. A person who has transitioned has, I believe, at least a prima facie responsibility to consider whether detransition in the short- or longer- term might perhaps be feasible for them. I will also argue that the choice to transition in the first place is rather more of an issue morally than is sometimes suggested – and not just because the dysphoria might in any case subside and/or be managed in less radical ways.

Modified adoption analogy

Let me propose a modification to the adoption analogy which I believe creates a closer analogy for medical and/or social gender transition as a treatment for dysphoria. Imagine a woman who wants to adopt a baby, but finds her infertility so painful psychologically that she wants to be treated in every possible way as if she were the baby's biological mother. She does not deny (at least to close friends and family⁷) that she is not in fact the biological mother, but both before and after she adopts she wants to give a very strong social impression that this is what she is. After all, she already feels like a biological mother – perhaps more so than does the real biological mother, she may say – as she waits for the child to be born, then ‘experiences’ the birth and takes the child home as her own.

Leading up to the adoption, the adoptive mother talks about her ‘due date’, wears maternity clothes and perhaps even takes medication to make her body more closely resemble that of a pregnant/labouring woman. After or just before the birth, following which (let's imagine) adoption papers will be signed immediately, she announces that she is in labour, leaves home with her overnight bag and checks as a patient into the relevant maternity ward. She then announces the birth when the adoption papers are signed, giving the time of the adoption as the time her child was born.

Note that this way of acting is not intrinsically morally objectionable – or not, at least, in every aspect. For example, it might be done – minus any lies – to protect the real biological mother and/or the baby in a society where ‘unauthorised’ pregnancies can result in serious harm to one or both. Yet although not intrinsically immoral, there would seem to be a fairly strong onus against this way of acting: it is not merely likely to lead to outright verbal falsehoods but itself ‘falsifies’ what should be a reliable social sign⁸ of something important: the gestation by, and birth of a child to, the woman who, as biological mother, has first responsibility for the child. Childbearing is too important, in regard to society's need to protect mothers and their role, and children and their well-being and sense of identity, for people to simulate childbearing without a sufficiently serious reason. Nor is this just a matter of deceiving people as to biological facts: even if the adoptive mother told everyone what was happening in reality – while continuing to look like a pregnant woman and speak of ‘my pregnancy’ – her language and behaviour would still involve a morally suspect ‘appropriation’ of words and appearances that do not belong to her.⁹

Gender transition and social meaning

While pregnancy is, of course, in some ways sui generis, there are some obvious parallels here. Indeed, there is even some potential overlap, in that we can imagine such a scenario in the case of a male-to-female transsexual adoptive parent,¹⁰ as well as an adoptive parent who is a biological female. But more generally: just as the appearance of a genuinely pregnant woman, and the social act of giving birth, are valuable in connecting biological children publicly to their mothers and (one hopes) their publicly-committed fathers,¹¹ so too, one's presentation as a gender concordant with one's biological sex has a valuable social meaning: the onus is against merely appearing to communicate the full meaning normally associated with that presentation.

There are some things it is important we know in interacting socially with each other. These include any close biological relationships in which we may stand to others, and the biological sex of potential marital/reproductive partners. Further, we need to identify potential maternal or paternal surrogates or role models: ‘grandmother’ or ‘grandfather’ or ‘uncle’ or ‘aunt’ figures or specific male or female supports such as female doulas. Note that these role-holders may not be sought for oneself, but for another in whose welfare we take a special interest: we may identify our child, for example, as needing a role model of his or her own sex and gender (perhaps due to the absence of a parent of that sex and gender who is able to take that role).

We do not, of course, identify these actual or potential role-holders by looking at their genitals – much less their internal gonads which are arguably most determinative of their biological sex.¹² Rather, it is normally through secondary sexual characteristics, plus clothes and behaviour, that people communicate, intentionally or otherwise, their biological sex to the world. Breasts, for example, do not merely have a nurturing function, but a communicative function: the reproductive-cum-social function of identifying the person who has them as a female. Just as a male peacock communicates through his tail, and a female peacock through her more discreet plumage, so human beings communicate what biological sex they are with their bodies, but also standardly their dress, hairstyle, jewellery and/or makeup. All that said, it is hard to stress too strongly the vast gulf between the primitive communications of peacocks and the rich and complex human communications (via bodily traits or social presentation) concerning actual or potential male or female biological and social roles.

Sexual stereotyping

Of course, there is, at the same time, a danger of putting too much stress on outward communication of biological sex: this can be positively harmful to those who are gender-atypical in some way. The person's very ability to accept his or her birth sex and gender may be threatened by too-rigid expectations of dress and behaviour in the playground and beyond. Although this paper is concerned with the situation of adults, it is worth noting that expectations of children that they be very ‘feminine’ or very ‘masculine’ are unfair to (among others) tomboys, or boys averse to rough and tumble play. Messages that such children are not ‘real’ girls or ‘real’ boys may be not only hurtful but damaging to their ability to identify fully with their own sexed bodies and the gender associated with them. A world in which such messages are suggested either maliciously in the playground, or by adults anxious to confirm a suspected transgender identity,¹³ is not a world in which gender-atypical girls and boys have their interests truly respected.

All that said, it is hard to deny that there is a real value in dress, body shape and voice giving some kind of cue – if only a subtle cue – as to the biological sex to which the person belongs. After all, from the perspective of traditional sexual ethics, marriage and marital acts are founded on complementarity in reproductive terms, even if many marital acts, and some entire marriages, are infertile and result in no conceptions. Those who believe in the polarity or complementarity of marriage and marital sex, and want to date only those they see as morally available potential partners, will recognise that it is important to know with whom one is socialising and may become sexually interested.¹⁴ Sexual attraction is often the result of social presentation: it is about how the person looks, sounds and acts, as opposed to being simply an immediate chemical effect of pheromones. Whatever the cue or cues, sexual attraction is biologically oriented at some level towards reproductive-type behaviour – of a kind that is, however, unavailable (in principle and not just in practice) if the person in focus is of the same biological sex. Moreover, even those who see no moral issue with same-sex marriage or same-sex relationships for other people may be averse themselves to dating those of the same sex, nor is it obvious that (as is sometimes suggested) this is sheer prejudice in the person concerned.

Turning to the area of role models, many will want role models of their own biological sex as well as social gender, whose experience of growing up and living as a male or female is not too diverse from their own. And many will want this for their children: perhaps especially parents of children who are struggling to accept their birth sex and gender may be looking for someone who can model for their child ways of living out that sex and gender which may not perhaps be typical but are nonetheless happy and successful. Again, such models may be sought even by those who do not object to transition for adults but are trying to circumvent for their children a lifelong rejection of their sexed bodies and reliance on hormones:¹⁵ surely not an ‘equally good’ outcome for the child as the acceptance of birth sex and gender which so often follows childhood dysphoria.

Modesty and transparency

There is also the issue to consider of modesty and transparency: attitudes protecting respect for sexual matters generally. Other things being equal, one should know in front of whom one is discussing such issues as male or female puberty, menstruation, pregnancy, male or female sexual behaviour and so on.¹⁶ Speech barriers can protect more important barriers, while in contrast, breaking speech and similar barriers can sexualise friendships, and in any case, seems presumptively unfair to those who have let their guard down under the impression that they are speaking to a biological peer.

Again, we need a caveat here: avoiding such social misperceptions is clearly not a moral absolute. After all, there have been many cases in history in which people have needed to dress as a member of the opposite sex for ‘external’ reasons – say, to avoid capture by enemies – where unavoidably, they have risked inappropriate confidences and perhaps even unwanted romantic overtures. So deception (which does not involve lying) as to sex and one's past history insofar as this reveals one's sex need not be absolutely avoided.¹⁷

However, the onus is certainly against such deception – even if the transitioned person will often have felt deceptive, rightly or wrongly, when the dysphoria was initially concealed before transition.¹⁸ And it is true that, rightly or wrongly, there are people, such as close friends and family, who may feel they should have been told sooner what their loved one was experiencing. However, a person's biological sex, as opposed to painful private feelings, concerns public roles and is something many of us expect to know about even casual friends, acquaintances and strangers - though there are certainly sometimes reasons why this expectation cannot be met. To give another maternal analogy: the fact one has a new baby is a public matter, concerning an important role, and the onus is against concealing it. It is far more a public matter than the fact that one has post-natal depression, and is perhaps struggling to see oneself in the role of mother at all.

When the transitioned person's biological sex is discovered, as it may be, relationships may be (not unnaturally) damaged – and this is not necessarily simply due to prejudice on others’ part. In the frank and insightful words of one detransitioned female to male commentator:

The simple, fair fact is that people become rightfully uncomfortable when another person tries to pass themselves off as something which they are not. Deception is a habit we learn well to identify as we live together in society.¹⁹

Masking versus bodily miss-signaling

Real as are the moral questions raised by ‘masking’ sex with external aids like clothes and makeup, there is, I believe, significantly more of an onus against coopting the body itself to signal opposite-sex type characteristics via use of cross-sex hormones. The body, unlike clothes, is of course one's very self and it seems particularly unfortunate when the very thing that has the function of sending out a signal (a flat chest for a man, for example) is altered to send out exactly the opposite signal in order for one to ‘pass’ as a member of the other sex.²⁰ Those who value ‘reproductive’ functions in the sense concerned immediately with sex and pregnancy should also value the social function of such secondary sexual characteristics which is also ‘reproductive’ in the sense that it is the normal way of communicating one's sex to potential sexual partners. While rejection of the sexed body involved in using cross-sex hormones may not be as radical as that involved in sterilising surgery, communication of sex is still blocked here deliberately at the level of one's very bodily self.

Cross-sex hormones go beyond the ‘mere’ suppression of functions found in use of contraceptive drugs or even puberty blockers²¹ (which is not to deny the serious ethical problems such suppressions normally raise). The aim with cross-sex hormones is to coopt one's very body to give out what is in reproductive terms a false message to others, as well as helping one avoid the painful experience of dysphoria by achieving a pleasing or reassuring effect. Body parts oriented to identifying the person as male or female, such as breasts or a male chest, are coopted and made to communicate something that, biologically, is not the case – however faithfully the change may express the person's psychological identification with the relevant sex and gender.²² Returning to the analogy of the adoptive parent simulating pregnancy: there is even more of an onus against taking drugs to simulate pregnancy and labour than there is against simulating pregnancy and labour (in the context of real life, not theatre) by one's dress, gait and so on.

Dating and sexual/marital behaviour

Returning to sexual matters in the central sense of the word: on a traditional understanding, sexual union is of course very much a matter of reproductive-type behaviour. Unlike raising a child which does not always have a strong reproductive reference (children can be adopted and raised by two sisters, a brother and a sister and so on) heterosexual intercourse is biological in a highly sex-specific way. It is (or can be) a matter of forming a ‘reproductive-type’ bodily union with another person, hopefully within a ‘reproductive-type’ marital commitment which protects both any child conceived and the spouses themselves. This approach to sex and marriage has an explanation for the general feeling that marriages should be life-long and exclusive, and that sex, unlike non-sexual expressions of affection, should involve a reasonably high level of consent. The approach sets sex apart from non-sexual activities, in a way that many feel intuitively is right, but which accounts more fully for the wrongness of such phenomena as polygamy and paedophilia, giving deeper reasons against these than do standard, more fragmentary approaches to sexual ethics.

Many people following the Sexual Revolution will reject, if not, thankfully, the ban on polygamy and paedophilia, some elements of the unified approach offered by traditional sexual ethics. That includes many same-sex attracted and/or trans-identifying people, many of whom – in a world so firmly shaped by post-Revolution sexual politics – would argue they are morally free to form relationships with those of the opposite gender, even if they are of the same biological sex. Alternatively, trans-identifying people may identify as gay or lesbian in relation to those who are of the same gender, but not the same sex – claiming again that such gay and lesbian relationships, as they see them, are no less valid than any other.²³

Gender dysphoria is about sexual and reproductive parts of one's body, and the social roles associated with these. Although not everyone will be interested in a sexual relationship specifically, when we think about cross-sex hormones and, in particular, genital and other surgery, it is worth remembering that many will have sexual relationships in mind (the neo-vagina, for example, will often be intended for possible sexual performance and not merely for allaying feelings of dysphoria²⁴). If there is indeed a problem with any sexual union that is not a true reproductive union (ie a ‘reproductive striving’²⁵ of the two linked bodies, however infertile in practice) then seeking to facilitate such a non-reproductive-type union will inevitably be a moral problem too. This is important to stress as it is easy just to focus on damage to the person's existing sex organs caused by sex reassignment surgery and/or long-time use of hormones: while such damage is certainly a serious moral issue (not dealt with in this paper) the construction of alternative sex organs is a serious moral issue also.

Gender-transition and parental/other modelling

It remains the case that some trans-identifying people will be sincerely uninterested, whether for moral or for other reasons, in enabling future sexual relationships following gender reassignment, being concerned merely with managing feelings of dysphoria in their everyday life. Even so, however, they will normally be attempting to communicate via their appearance something to others as well as perhaps to themselves, and the question still arises for the individual person whether they have enough justification for tacitly communicating a message that is not accurate, at least as regards their biological sex (bearing in mind that the person will often want to ‘pass’ as a member of that sex, not just the associated social gender).

Still, someone who accepts a traditional view of sexual ethics in regard to sexual behaviour, including same-sex behaviour, could nonetheless experience dysphoria to an extent that leads the person to transition, or at least to consider this very seriously. Such a person may consider that since they are not/will not be a member of the opposite sex following transition, they should not date members of their own sex: they may see biological sex as morally determinative for all romantic and sexual purposes. If the person is currently unmarried, they may plan not to marry at all, perhaps because they do not believe they fulfil the criteria for a valid marriage; irrespective of this, they may believe that (for example) cross-sex hormones and crossdressing are the only things likely to help significantly with their long-standing dysphoria. The question for them, as they try to discern the best way forward, may be whether there is a moral objection to transitioning (or staying transitioned) medically and/or socially, simply as a palliative measure.

What should someone in that situation do? As mentioned earlier, I am leaving aside very serious questions raised by surgery and indeed, the sterilising effects of long-term hormone use (bearing in mind that sterility may well be intended by those for whom fertility is itself a source of distress²⁶). These matters raise concerns regarding legitimate and illegitimate applications of the ‘principle of totality’ which will not be pursued in this paper. My concern here is more with the social implications of the use of surgery and/or hormones and/or social transitioning, those other important issues aside.

Transition: responsibilities of the person

When contemplating a possible transition in the future, one thing that needs to be seriously considered is the effect on others, beginning with the person's family. Some of those wishing to transition may be married (even if questions of validity may arise depending on when their strong dysphoria developed) and the rights and feelings of spouses must of course be taken very seriously indeed. Nor is it only a matter of spouses’ rights and feelings: often there will be children involved. Young children, in particular, do not have the cognitive sophistication to hold in mind that this person, their father, really is male but only looks female and wants to be called by a female name and pronouns. Witnessing trusted adults calling one's father by a female name and pronouns is not conducive to children developing a healthy sense of realism. How are children supposed to engage with reality when the adults they look to to help them interpret reality say X is Y and Y is X? ²⁷

Fathers wanting to cross-dress or transition will or should be concerned to act as good role models for their children – perhaps especially their male children. A crossdressing father, let alone a medically transitioned father,²⁸ does not model masculinity in a way that is helpful to his sons, as one former crossdresser has explicitly noted.²⁹ These issues are all the more pertinent as some studies have found that married autogynephilic crossdressers are more likely than others to respond to alternative therapeutic approaches³⁰ to identifying as a woman or even crossdressing part-time.³¹

Another serious concern is the need to be a good role model to young people generally, who are growing up in a world where their sense of masculine or feminine identity may be fragile, due to a combination of innate vulnerability and social contagion. The latter is an all-too-real phenomenon: in the words of a recent paper on ‘rapid onset gender dysphoria’ (ROGD) seen through the eyes of parents:

The elevated number of friends per friendship group who became transgender-identified, the pattern of cluster outbreaks of transgender-identification in these friendship groups, the substantial percentage of friendship groups where the majority of the members became transgender-identified, and the peer group dynamics observed all serve to support the plausibility of social and peer contagion for ROGD.³²

Teenagers can be influenced not just by members of their friendship group but by adults whom they like or admire. When a popular female coach came out as transgender, the same paper reports, not just one but four teenage girls announced that they were transgender themselves. In considering transition, a gender-dysphoric adult who recognises that teenagers (or at least, the great majority of teenagers) should deal in other ways with gender anxieties should carefully consider the risk of influencing such vulnerable young people who can and should remain in their birth gender.³³

Transition: responsibilities of others

Turning to those around the gender-dysphoric person, they too should ask themselves about the effect of endorsing/seeming to endorse transition – effects both on the person and on others which may arise from using preferred pronouns, for example. True, it is not intrinsically wrong to use pronouns that do not belong to a person's biological sex and the associated social gender (for one thing, this is something potentially appropriate for intersex people who may also be currently living in a gender not associated with their true biological sex). But friends and family should be concerned, not just with what is wrong intrinsically (ie, in all conceivable situations) but with what is wrong in practice, here and now. Very often there will be a strong risk of giving the message, to the transitioned person but also to others, that the person is a male or female not just in presentation but in all important respects. That is a message family and friends should be very reluctant to give, whether intentionally or otherwise.

Quite generally, it is common and reasonable practice when relating to those with painful vulnerabilities to try to avoid causing unnecessary pain. Gender dysphoria is certainly no exception, nor need avoiding triggers involve deliberately or even recklessly helping the person and others believe that for all important purposes, the person is the sex and gender they identify with or want to be. For one thing, merely helping the person avoid painful reminders of something that distresses them may be compatible with the person's attention not being drawn to the issue particularly, as they will then focus more on other things. That might be the case if pronouns are avoided altogether – though such avoidance may itself become distressingly obvious, of course, as time goes on.³⁴

It is important to have honesty in families in particular: while use of an opposite-sex pronoun is not exactly a lie (the gender-dysphoric person may realise all too well that it does not betoken agreement that the person is ‘really’ ie for all important purposes the desired sex and gender³⁵) such use may nonetheless fail wrongly to witness to reality as regards the person's sex and its continuing moral and social importance.³⁶ Moreover, forms of compliance like using opposite-sex pronouns can lead to deeper questions of complicity, as when a brother then proceeds to ask his sister to introduce him to her friends as her sister or girlfriend.³⁷

Just as there is an onus against helping someone simulate pregnancy and labour – even if this could be done morally for a sufficiently serious reason – in a somewhat similar way, there is an onus against using non-birth sex pronouns, even without any actual lies, which also needs a sufficiently serious reason. (As regards use of language, to choose not to refer to the adoptive mother in our earlier analogy as a ‘birth mother’ or ‘woman going into labour’, despite her strongly wanting this, and even in a situation where everyone knows that these terms are not being used literally, seems presumptively, at least, the right thing to do. That is rather different from avoiding as too upsetting any reference to the child's actual ‘birth mother’ or ‘biological mother’ – avoidance which may be not only kind and courteous but quite possibly morally required.)

It is worth remembering in any case that the social and medical transition that friends, family and others are being asked to support will not necessarily even decrease the person's distress in the long term. As one therapist comments, in an open letter to a teenager considering transition:

Those who identify as transgender can suffer from pangs of cognitive dissonance. This can often make the dysphoria worse. I have heard many stories from desisters and detransitioners that identifying as transgender made them feel worse, because they then had to deal with a constant tension around the fact that their body looked and acted differently than how they thought it should. This can invite obsessive, perseverative thinking, which can be draining and cause increased distress and anxiety. Adopting a belief that contradicts material reality can be a recipe for unhappiness, as we will likely feel the need to strive to become the thing we are not. This is part of the reason many wisdom traditions and psychotherapy schools direct us to cultivate acceptance of those things we cannot change.³⁸

In the words of someone who has since detransitioned:

“I was not living in truth, regardless of surgery, legal declaration, and proclamations of diversity, and tolerance.”³⁹

Even if not all who have already transitioned are similarly called to detransition, we should not be surprised by the growing list of those detransitioning even after many years living in the new gender and after radical and perhaps irreversible interventions. Such individuals now oppose too-ready recourse to self-labelling and transition as ways of dealing with dysphoria; and call for alternative approaches, whether therapeutic⁴⁰ or in terms of self-care⁴¹, which are sometimes given short shrift in common ‘trans-narratives’ where the message often given is: transition or die.

Acceptance and external expression of biological sex the ideal

Accepting and even gratefully accepting one's sexed body, and trying to conform one's perceptions to that body (to the extent one focuses on it at all⁴²), must remain the ideal, bearing in mind that in traditional sexual ethics, biological sex may not be dismissed as ‘merely’ biological but is already fraught with marital meaning. Nor does acceptance of the transitioned person as a loved and valued person like anyone else require ignoring their biological sex which, in traditional sexual ethics, is alone relevant to issues such as choice of dating and marital partners.

A person's social male or female role should ideally ‘track’ his or her biological sex, which is important for social interactions of various kinds. In particular, biological sex is crucial to roles such as husband or wife (or potential husband or wife) and mother or father (or potential mother or father). The gender-dysphoric person may already have a spouse and children, on whom the effect of transitioning will not be trivial, and may indeed be devastatingly painful. Transition can give a false impression concerning the interchangeability of the sexes for sexual and not just for social purposes, even if the person is in fact celibate. Those who do not marry and have children can also have important roles in terms of biological sex and gender: son or daughter, brother or sister, uncle or aunt, good/bad male or female role model for those around them.

To repeat: none of this is to say that those who are currently living in a gender discordant from their true biological sex must cease and desist immediately, whatever their state of health or personal circumstances. Crossdressing and even use of hormones simply as a palliative measure to stave off anxiety and/or depression and/or suicidality is not an absolute moral wrong. Even those who may indeed be called to move (back) to the gender associated with their true biological sex are not necessarily called to do so immediately. If one is an intersex person who has only just learnt that one's biological sex is divergent from one's gender of rearing, one may surely be allowed some time to process this before reversing one's wardrobe and changing one's pronouns – even assuming that this is the best way forward.

Nonetheless, those who are mentally and physically able should, I would argue, make social expression of their biological sex an ultimate goal if they can, recognising the value in terms of key social roles of harmony between biological sex and social expression. And as regards initial medical and/or social transition, again, the effects on others will clearly need to be considered, including effects on young people who are not currently strongly dysphoric but are vulnerable to influence and example.