Margaret Anne Bulkley lived the last 56 years of her life disguised as a man. At about the age of 20 she took on the persona of James Barry in order to Matriculate at Edinburgh University and study medicine. Following this, in order to practice medicine, she maintained this pretence by living as a man until her death. When she died in 1865 (coincidentally the year Elizabeth Garrett became the first woman to qualify as a doctor) she had pursued a successful medical career and been promoted steadily becoming Medical Inspector General for South Africa. During this period of pretence it is believed that she managed also to give birth to a daughter while the world still respected her as a successful and powerful man.
We only have to look back a little time to see how much progress we have made. In the past so many of our personal and social roles were held to be closely tied to our sex at birth. Today we do not bat an eyelid when a woman wishes to be a surgeon, a man a nurse, a girl a footballer or a boy a dancer. We don’t think of very many roles being necessarily tied to biological sex. The days when women had to pretend to be men to pursue their desires have gone.
We should remember the travails of women who wanted to pursue aims at the time which were held to be only suitable for men – Joan of Arc as she tried to lead armies, Dorothy Lawrence who worked as a war reporter, Margaret Bulkley wishing to be a doctor, and countless women who fell in love with other women. Remembering these women will stop us forgetting the ignominious aspect of our history which forced pretence on the few who were able to follow their dreams and stopped so many from even taking their first steps towards them.
We now tend to think there is a rather loose relationship between gender roles and biological sex. Something that is more important for groups and averages than something to be applied to individuals. The biological differences we have are often subtle, and may help explain why one group is over-represented in one area or another, but are rarely felt to be important for the individual in their selection of, or for, activities.
If a child is born today with desires and aims that have been traditionally been seen as the domain of the other biological sex this is not an insurmountable problem. They may face some resistance, but as society improves this should lessen, but there will be no need for transvestitism, nor any pretence. They can aim for their dreams regardless of their biological sex. They don’t have to don the clothes, or names, of the other sex and they don’t need to hide or alter their biology.
Thus there would seem no call for a boy who wants to follow gender roles traditionally seen as female to transition and alter their biology. Likewise any girl who wishes to pursue traditionally masculine roles or activities need not alter their bodily appearance. The gender roles that we are often concerned about may have some of their historical development related to our biology (increased muscle mass may have lead us to see the army as a masculine role, for example) but most now are determined purely socially. Thus if someone feels the roles that they wish to pursue are discordant with their biology then the solution is social. The solution is to push for that role to be open to both biological sexes not to alter the person’s biological sex to fit the social role.
If people want to change their biological sex it must be for reasons other than wanting to pursue what are felt to be sex-inappropriate roles as the barriers facing them are considerably less than the barrier posed by the option of changing one’s biological sex. It would seem that the term gender dysphoria does sum up the primary reason for the desire to transition to the other biological sex. It is not a positive desire to be the other biological sex but rather a distaste or unhappiness (dysphoria) in being in the body you find yourself within.
This is not an unusual feature of psychological disorders arising in early adult life and especially around puberty. In addition to gender dysphoria, dysmorphophobia (a belief that one is disfigured or deformed) and the eating disorders (anorexia nervosa and related disorders) share the core belief by the patient that their body shape or configuration is wrong for them. These are serious, debilitating, and dangerous disorders with extremely high levels of distress and a significant mortality through suicide. Our understanding of these disorders is very poor and our treatments are of only limited efficacy. But we never mistake the faulty body image of the patient with anorexia, or dysmorphophobia, as the solution and make that the target of our treatment. We never offer pointless plastic surgery someone who believes their face deformed nor accept that the patient with anorexia should just continue to fade away and die as they see themselves as too fat. Instead we try and help them adjust to their body, and life, as it is and find ways to live with this.
Unfortunately with transgender patients we break with this tradition and offer to try medications and surgery to make their body fit with their internal thoughts. If such medication and surgery diminished distress and eased the patient it might be seen as a useful, if surprising, therapy. Unfortunately it does not appear to do so. The evidence is scanty but, as the American College of Paediatricans pointed out, work undertaken by Sweden’s Karolinska Institute does not find that surgery to transition people from one sex to another reduces the rate of suicide which remains, sadly, much higher than that in the population as a whole.
I have steadily lost the certainty of youth as I have grown older. I am now much happier to accept that I do not know the answer to many questions. Increased knowledge and experience has lead to reduced acceptance of simple or glib answers. However, although I may not know what to do I sometimes know what we should not do. In this case, whether people want to pursue a life in the gender roles that differ to those of the body they were born within, either from a desire for the positive aspects of those roles, or from a disgust of their own bodily configuration, then attempts to alter their biological sex would appear unwise. At an individual level, obviously it is their choice and they may do with their bodies as they will, but any unbiased observer would counsel them against this as it is unlikely to lead them to future happiness. At a societal level, I fear we may look back on this period sadly; we saw the problem of defining peoples’ roles by their genitals which forced the likes of Margaret Bulkley and others into dreadful situations but came up with the solution of making peoples’ genitals match the gender roles ! History may not be kind to us.