No room for sex

The gender-affirming world turns on a denial of reproductive reality

Photo by Oleg Sergeichik on Unsplash

What disturbs me most about gender-affirming care (GAC) is that so many health professionals are convinced it is a safe and appropriate treatment—indeed the only treatment—to use with gender-questioning young people. For many years, GAC appears to have been broadly accepted with minimal criticism and reviews were generally supportive of the safety and benefits for gender-questioning minors.

There are two broad categories in the transgender debate: GAC for minors (under 18)¹ and the impact on female rights of self-ID by adult males. These are different discussions but rely on the same theoretical assumptions.

The appearance of consensus

Why has it become a contentious issue now, with calls for a review of guidelines in many jurisdictions, when for so long the claim was “the science is settled” and there was “no debate”?

I used the word appears, above, for a reason: it wasn’t that there was no concern among health professionals, but rather, there was a planned and deliberate strategy by trans activists to silence any opposition.

This strategy was outlined by Dr Jack Drescher, an American psychiatrist and psychoanalyst known for his work on sexual orientation and gender identity. From 2007, he was a member of the American Psychiatric Association DSM-5 Workgroup on Sexual and Gender Identity Disorders.

In 2009 he authored a paper which gave a list of recommendations to “normalise” explanations of transgender identity, such as the belief that a person is born trans rather than influenced by external factors. His other recommendations included—

“adopt and insist upon the use of normative language to replace medical terminology

“label theories that contradict affirmative perspectives as unscientific

“ad hominem and ad feminam attacks on professionals who challenge”

The list of strategies described by Dr Drescher was refined in the 2019 Dentons report, and the noteworthy one relevant to this article is to “Use human rights as a campaign point”.

In summary, trans activists were advised to insist on “inclusive” language (for example, “children” instead of “boys and girls”) to attack on a personal level any woman or man who raised concerns about the assessment and management of gender-questioning people (“bigot”, “transphobe”), to rubbish any research regardless of its scientific merits (“anti-trans”, “biased”), and to present trans people as “vulnerable”, “marginalised” and likely to suicide if not affirmed—all this as an emotional appeal to target any objectors as heartless bigots. Sound familiar?

My first run-in with trans activists occurred in 2020 when I, in all innocence, wrote a letter to the editor of the Australian Psychological Society (APS) magazine InPsych about the lack of a sound and comprehensive assessment process for the increasing number of young gender-questioning people I was seeing.

I had always worked with such clients but previously they were adult males. I suppose I should have been prepared for a backlash when the editor phoned me to let me know they were concerned about publishing my letter because many psychologists thought we should not be acting as “gatekeepers” for access to affirming care. The idea is that if someone says they are trans, they are trans—no need for an assessment.

To their credit, the APS did publish the letter, and I took part in a podcast outlining my concerns. And then the backlash really hit. A formal complaint was made to the APS, which could have had serious consequences for me, but in 2021 the APS to their lasting credit became the first professional society in the world (to my knowledge) to support a clinician’s right to their clinical opinion in the contested field of gender.

Others have not been so lucky. One of the first casualties was Dr Ken Zucker, an American/Canadian clinical psychologist who once ran the largest public clinic in Toronto for treating children and adolescents with gender dysphoria. He lost his job in 2015 after a smear campaign which was later found to be based on lies.

I have had colleagues tell me about being referred to the Australian Health Practitioner Regulation Agency, which has the authority to remove a clinician’s right to practise, simply for expressing concerns about GAC. Even when the complaint fails, the health professional is left with the impact of the stress and distress of the process, which has served as a warning to all practitioners to stay quiet.

---

Video: Dr Louise Kirby, of the Australian Doctors Federation, outlines her concern about gender medicalisation of minors. The federation is a group small in number and dedicated to the independence of the doctor-patient relationship

Media bias

It isn’t just the health professions that have tried to silence any critics of GAC. Many media outlets are reluctant to publish articles that might be considered “anti-trans”, while they routinely publish “pro-trans” content, although that imbalance is slowly changing.

However, beyond the failure to publish articles questioning modern gender theory, some media go out of their way to glorify trans. A recent article in Newsweek paints a sympathetic story about Steven Hayes, a man who is serving six life sentences for the 2007 murder of Jennifer Hawke-Petit and her two daughters, Michaela and Hayley.

Instead of expressing disgust, the journalist explains that this man had been struggling with gender identity but now feels so much better after the prison service paid for his medical transition to become a woman named Linda Mai Lee.

Similarly, in Australia in 2024 a trans-identified male was convicted for the horrific sexual abuse of his own 5-year-old daughter; he was sentenced to just over 4 years because his claimed gender confusion was regarded as a mitigating factor.

Where are the editorials deploring cases like these?

It’s clear that the long game played by trans activists over several decades has been stunningly successful. Never in my five decades of clinical practice have I experienced such an organised, weaponised lobby group so successfully push an agenda that now is being shown to be seriously flawed.

There is a history of dangerous health practices predating GAC but debate was always allowed, and eventually those previous practices were changed or abandoned. The challenge to GAC still has a long way to go.

Consider this statement from a 2023 article: “The moral panic and hate-fuelled backlash against gender-affirming care and trans people may seem to have erupted from nowhere.”

There are many rejoinders to that complaint, ranging across mental health, religious, cultural and political arenas. Health professionals who are concerned about GAC tend to work within a biopsychosocial framework (BPS), with the view that “mental health [can] be affected by three main areas that are encapsulated in the biopsychosocial model—

“Biological (for example, genetics, brain chemistry and brain damage)

“Social (such as life traumas and stresses, early life experiences and family relationships)

“Psychological (for example, how we interpret events as signifying something negative about ourselves)”

It is well-documented that gender-questioning young people have a high rate of mental health problems such as depression, anxiety, and ADHD.

Health professionals who practise GAC prefer to claim that such mental health issues are due to the prejudice and lack of support these young people experience for being trans—so-called “minority stress”—rather than consider that the young person may be responding to social influences in believing that gender transition will improve their mental health.

GAC supporters deny that social factors may be at play, yet the evidence that young people are being manipulated to believe they suffer from a variety of medical conditions—ADHD, neurological tics and so on—is clear indication that social contagion must be considered in any mental health evaluation.

Dr Drescher, a leading GAC advocate, acknowledged in 2023 that for a gender identity disorder² there is a “lack of reliable markers to predict in whom it would or would not persist”. This represents not only hypocrisy but a breach of the clinical duty of care.

Gender-affirming practitioners insist that any assessment and treatment must be “led by the child”. They argue that a person shouldn’t have to “prove” they are trans, and that there should be no “gatekeepers” in the way of a gender-questioning person’s desire to begin social and perhaps medical transition. Gatekeeping is said to refer “to clinicians’ strict application of eligibility criteria to determine a trans patient’s ‘fitness’ to engage in medical transition, resulting in significant barriers to gender-affirming care.”

The underlying assumptions of gender-affirming care

From the viewpoint of a mainstream health professional, the modern gender theory underpinning GAC is based on several false assumptions which inevitably lead to inappropriate treatment for clients. To understand how these assumptions became the bedrock of modern gender theory, it is necessary to go back to the beginning of trans activism.

Current GAC protocols arose out of the growing influence of Queer theory in university departments across the western world, especially from the 1990s. Queer theory is said to be “a critical theory that examines gender and sexuality as social constructs, and challenges the idea that heterosexuality is the norm.”

Initially Queer theory focused on sexuality in general, arguing that sexual orientation was not biologically driven but a social construct to support the “heteronormative” culture.

In this way, it was argued that—

“Heteronormativity assumptions, then, are viewed as socio-political tools that limit persons’ ability to pursue non-normative desires and behaviours. Heteronormativity is a power regime.”

It was in this context that Dr Judith Butler, described as an American feminist philosopher and gender studies scholar, used the term “performative” to explain that gender is a social construct that varies over time and place. In simple terms she is saying that one has to perform according to the expectations and rules associated with being female in order to be accepted as a woman; thus, conversely, anyone (that is, a man) who “performs” like a woman is a woman.

This of course is not the case, as being gender nonconforming may have in the past brought judgement and criticism for some adult females but there is no evidence that they are or were regarded as “not a woman”—

“The term ‘gender nonconforming’ was first recorded in 1991, but the concept of gender nonconformity has been documented throughout history.”

Dr Butler likes to use complex, dense language to describe something that is straightforward but wants to project the idea that she has had a new amazing insight. Her “insight” that gender relies on social norms is not new. She is merely paraphrasing what decades of research by anthropologists, social psychologists and others revealed. She apparently is unaware of the work of Margaret Mead, the famous 20th Century anthropologist—

“In contrast to this static and binary vision of gender differences, Mead proposed a more dynamic and culturally relative perspective. Through her studies in various societies, Mead observed that gender norms and expectations were not universal or biologically determined, but were influenced by cultural and social factors.”

To untangle Dr Butler’s thesis on transgender identity takes patience but is rewarded by recognising the sheer banality of her claim to fame—

“Biological sex is also a social construction—gender subsumes sex. According to this view, then, the social construction of the natural presupposes the cancellation of the natural by the social. Insofar as it relies on this construal, the sex/gender distinction founders ... if gender is the social significance that sex assumes within a given culture ... then what, if anything, is left of ‘sex’ once it has assumed its social character as gender? …

“If gender consists of the social meanings that sex assumes, then sex does not accrue social meanings as additive properties, but rather is replaced by the social meanings it takes on; sex is relinquished in the course of that assumption, and gender emerges, not as a term in a continued relationship of opposition to sex, but as the term which absorbs and displaces ‘sex’.”

To translate, her argument runs like this: gender is performative, therefore women are defined (only) as a woman by how they behave, so anyone who performs as a woman is a woman, and because of this, sex must also be a social construct, which means that gender replaces sex, and since social constructs change over time, it is possible for a person to change sex.

By contrast, the leadership board of the Gender Dysphoria Alliance, an organisation for people with that condition, states—

“We believe it’s highly important for people with gender dysphoria such as ourselves, whether we medicalise or not, to retain awareness of our biological sex. Because it’s not truly possible to change sex, accepting our full reality as transpeople is important for both our psychological and physical well-being.

“Psychological integration requires that we accept our full, unique reality as it is. We cannot address the dissociation we experience otherwise.”

Further, Dr Butler’s discussion of the “performative” nature of gender extends to sexual orientation. Apparently, because gender and sex are social constructs that lay down rules about acceptable behaviours, both heterosexual and homosexual orientations are also “performative” and unreasonably limit all other options.

Dr Butler and her acolytes take this leap out of the realms of biological reality for the longer-term goal to normalise any and all forms of sexual expression and behaviours, including but not limited to bestiality (zoophilia) and paedophilia. In 2016, American academic Dr Jesse Bering wrote—

“Perhaps we should take a hard look in the mirror and ask whether excluding Zs and Ps and others from the current tolerance roster isn’t doing to them precisely what was once done to us.”

What is missing from Butler’s analysis?

What is the one thing that all species, animal and plant, have in common? The one imperative for all these many and diverse living things? The answer is to continue to exist—

“‘Survival of the species’ means the ability of a particular species to continue existing over time by maintaining a stable population and adapting to environmental changes, essentially avoiding extinction through reproduction and passing on beneficial traits to future generations; it’s closely linked to the concept of natural selection and ecological balance within an ecosystem (Emphasis added).”

Without a reliable, stable, effective reproduction strategy, we humans would soon become extinct, but for their own reasons Dr Butler and other Queer theorists choose to ignore this universal reality.

If, according to Dr Butler and others, sex is a social construct, for that to be true, each society would have its own reproduction strategy. And this is where transgender theory should, if the GAC health professionals review their education and training in human biology, completely unravel.

How are babies made?

Given that GAC practitioners dispute the explanations by people such as evolutionary biologist Colin Wright and developmental biologist Emma Hilton that sex is binary and immutable, it falls to these practitioners to give a coherent account of their beliefs about human reproduction.

UNESCO, UNAIDS, UNFPA, UNICEF, UN Women and WHO—all out-and-proud allies of modern gender theory—nevertheless found that the only way to explain puberty and sexual reproduction to children was to refer to women and girls (females) and men and boys (males)—

“Women’s bodies can release eggs during the menstrual cycle, and men’s bodies may make and ejaculate sperm, both of which are needed for reproduction (Emphasis added)

“Puberty: however, for boys, the shift of puberty is much more explicitly linked to sexual feelings in a positive way, whereas for girls this moment often marks the beginning of conflicting messages about sexuality, virginity, fertility and womanhood

“Pregnancy can occur as a result of sexual intercourse during which a penis ejaculates into the vagina

“Sex: biological and physiological characteristics (genetic, endocrine, and anatomical) used to categorise people as members of either the male or female population”

Note that there are only two participants in the reproduction process, in which an egg from a female is fertilised by sperm from a male, and this is the same for all humans regardless of the society in which they live.

GAC and biology

GAC rests on denying the biological reality that sex is binary and immutable. As happens in a hothouse of activism, people often skim the surface of the underlying arguments and unconsciously or deliberately interpret what they hear to suit their own agenda.

Perhaps it is because reproduction has become a choice—as contraception has become more reliable—that transgender activists have been able to sell the idea that sex is about something else. So, why don’t they explain what that “something else” is?

Queer theory advocates use the existence of disorders of sexual development (DSDs), sometimes referred to as intersex, to assert that there are more than two sexes and it is possible for a person to change sex, that sex is assigned (rather than observed) at birth and the assigned sex may be incorrect.

In more recent times, differences in sex development have been described by some health professionals as natural variations, not a disorder:

“‘Intersex’ is the term that a person may use when they have both male and female sex characteristics. These include genitalia, hormones, chromosomes, and reproductive organs. Being intersex is not a disease. It is a naturally occurring variation in humans.”

This reframe allows disorders of sexual development to be used to deny that sex is binary by inferring that each DSD represents a different sex; defining female as XX and male as XY is now said to be out of date and transphobic—

“Beyond the Sex Binary: Toward the Inclusive Anatomical Sciences Education … the binary division in male and female sex has been called into question and a more fluid understanding of sex has been proposed.”

The attempt to use DSDs to support an argument that sex is a spectrum and there are more than two sexes fails on several levels—

Sex characteristics are confused with ‘sex’, but sex is about the function of reproduction

For sex to be a spectrum, the XX→XY axis would require for the second X to imperceptibly change from an X to a Y, which does not happen

Even if that were possible, the DSDs would not have a place on that axis because there would be no gradual transition to allow for that addition or subtraction of additional chromosomes. A spectrum is defined as “a condition that is not limited to a specific set of values but can vary, without gaps, across a continuum”

The argument that sex is bimodal suffers from the same error:

“The ‘sex is bimodal’ argument conflates sex-related traits, such as facial hair, voice pitch, height, and muscle mass, with sex category itself. These traits, such as voice pitch, are highly bimodal, with an average for males and an average for females.”

Just as DSDs do not support the argument that sex is a spectrum, they cannot be used to support the argument that a person can change sex by changing to their preferred gender role.

While some DSDs appear to induce a change of sex at puberty—for example, 46,XY DSD with 5α-reductase deficiency—this is an effect of the disorder and has no implications for those without that disorder.

In summary

Sex is binary: every person on the planet exists because an egg from a female was fertilised by sperm from a male. There are no in-between sexes that contribute to this system of reproduction: two and only two sexes, female and male, exist and maintain the survival of the human species.

Sex is immutable: just renaming body parts—“penis” as “ladydick”, for example—does not mean a person has changed sex.

A girl is a female child, a woman is an adult female, a boy is a male child, a man is an adult male.

Sex is universal, gender is cultural.

Modern gender theory in action

In the UK, nurse Sandie Peggie is suing her employer NHS Fife and colleague Dr Beth Upton, a medical practitioner who was born male but identifies as a woman, after she was suspended for objecting to his presence in the female changing rooms. Following are excerpts taken from media accounts of Dr Upton’s testimony—

“Dr Upton replied: ‘The term biologically female or biologically male is completely nebulous. It has no defined or agreed meaning in science, as far as I’m aware. I’m not a robot, so I am biological and my identity is female … I’m biologically female.’

“The doctor went on to claim that the term biological sex ‘doesn’t really mean anything’ as it was impossible to ‘accurately or usefully define’ what it meant.

“‘We would have to explore all the different things that makeup one’s sex,’ Dr Upton added, saying this could encompass ‘endocrine sex’, ‘primary and secondary sexual characteristics’, ‘reproductive sex’, ‘societal, cultural and assumed sex’ and other factors.

“Dr Upton added: ‘Not all those things are what you might call concordant with the other. There are very few people who don’t think [that] understanding of some aspect of somebody’s biology is important in some situations. But there is no agreed definition of biological sex. It’s a nebulous dog whistle’.”

“Asked how … ‘medical assignation’ of sex happens, he suggested that doctors would ‘make a best guess if they can... [it’s] not always clear, I’m not an obstetrician’.”

Conclusion

These are the foundation beliefs of health professionals who provide gender-affirming care. If they don’t know what sex is, what the purpose of sex is, and don’t know how babies are made, how can they be trusted to provide safe treatments for any troubled young people questioning their gender?

Dr Sandra Pertot retired not long ago after 50 years of practice as a clinical psychologist specialising in human sexuality, including sexual dysfunction, sexual orientation and gender diversity

1. GAC health professionals refer minors for puberty blockers, cross-sex hormones and in some cases surgery such as double mastectomy.

2. Gender identity disorder was the diagnostic term used before gender dysphoria.