I’M NOT BOY!” A

If your child’s assigned gender is causing nothing but distress, could he or she be transgender?

From when she could speak, Jen and Gary’s son Alex* talked about “sparkly cupcakes and shiny fabrics,” Jen remembers. “I like to think we brought her up as a normal little boy, surrounded by trucks and train sets that she had zero interest in.”

By three years old, Alex was asking for dresses, and – considering themselves the sort of family who did not rigidly enforce gender roles – Jen bought her son “dress-up” dresses – “because all kids have dress-up outfits, right?” But Alex was hip to their tricks, asking specifically why she couldn’t have ordinary girls’ clothes from the girls’ department at clothing stores.

Because the expressed gender dysphoria and distress was so strong, the family decided to take Alex to a psychologist. “He warned very strongly against our approach, suggesting that we were doing Alex’s gender identity damage and that the dresses and long hair must go and male role models and icons must be promoted,” Jen recalls.

So began an unhappy time in this Cape Town household. Alex showed signs of depression and the home was a battle zone as arbitrary lines were drawn and fought over: “How tight can your pants be before they are for girls only, and why is a kilt okay, but not a tutu?”

When Alex was four, psychiatrist Dr Simon Pickstone-taylor, who works with transgender children at Red Cross Children’s Hospital and Groote Schuur Hospital, entered the child’s life, and everything changed. “He assured us that an increasing body of scientific knowledge showed that supporting appropriately assessed children to live as the gender they identify as has the best outcome in terms of longevity, mental health, and behavioural issues.” Alex was back in her dresses, and the family found peace in allowing their child to express herself, and adopted a watchand-wait approach for later years.

BEYOND THE BINARY Western society has used binary opposites to make sense of the world: black and white, left and right, up and down, right and wrong, gay and straight, male and female, self and other. But what, asked the next generation of thinkers, about all the things that are not 100 percent one or the other, but a little bit of both?

Feminists and identity theorists noted that one half of the binary is usually favoured. Which binaries are seen as “the norm”, and which are overlooked, or oppressed? Which terms have more power? Looking at the process of constructing categories (and deconstructing them!) is not the fanciful invention of left-leaning thinkers and social disruptors only. New scientific knowledge has forced us to collapse many of our simple binary opposites, and consider that many of these occur along spectrums.

Let’s take a short detour through how boys and girls are made, then.

XX, XY, IS NOT THE WHOLE STORY Most of us know from school science or biology classes that human beings have 46 chromosomes in their DNA. The final pair, pair 23, is two X chromosomes, XX for women and XY for men. As Lise Eliot explains in her book Pink Brain Blue Brain, “as scientists only recently discovered, it doesn’t take the whole Y chromosome to make a boy, merely one microscopic stretch of DNA, known as SRY, scientific shorthand for ‘sex-determining region of the Y chromosome’.” Astonishingly, this SRY gene can “jump aboard one of the X chromosomes during sperm formation”, resulting in XX males who think, feel and act like men, though they look anatomically like women – and the reverse, XY women with a missing or mutated SRY gene, who know they are actually men inside female bodies.

And we are only just beginning to understand the science – there may be more surprises waiting. Suffice to say male/female is not the uncomplicated binary we always thought it was. There is at least a third sex – intersex – and we can expect classifications to refine.

In National Geographic’s January 2017 issue devoted to gender, Robin Marantz Henig writes, “Genetic variations can occur that are unrelated to the SRY gene, such as complete androgen insensitivity syndrome (CAIS), in which an XY embryo’s cells respond minimally, if at all, to the signals of male hormones.

Male genitals don’t develop. The baby looks female, with a clitoris and vagina, and in most cases will grow up feeling herself to be a girl. Which is this baby, then? Is she the girl she believes herself to be? Or, because of her XY chromosomes – not to mention the testes in her abdomen – is she ‘really’ male?”

Other genetic variants include XXY, XYY, single X, and other, more rare, combinations. Sex just really isn’t an either/or anymore.

MYTHS BUSTED You can let your tomboy daughter climb trees and your boy child paint his toenails without worrying that they are showing signs of gender identity confusion. “All children explore gender. There are even genderfluid or gender nonconforming children,” says Ronald Addinall, a UCT academic, clinical social worker and sexologist, who volunteers at the Triangle Project, a LGBTQIA+ support organisation. “There is no evidence that being transgender is caused by cold mothers, or absent fathers, or any other social causes.”

There are not suddenly more transgender people around, either – it’s not the fault of food additives, hormones in the water or vaccines (yes, those are real theories!). Rather, people are more likely to disclose their identities in a more welcoming environment, whereas in previous generations they may have stayed silent and endured their secret alone. (It’s worth noting suicide risk – already high in teenagers – is even higher among teens battling gender identity issues in an unsupportive environment.)

“We do still live in a binary society and the majority of individuals do still find a fit inside the binary,” says Addinall. “Usually,” he adds, “a child is assigned a gender, and then all the social scripts are enacted with regard to the expected gender of the child. And for the majority of the population this is a good fit. But what we know today is that there is a significant proportion of people for whom their natural genderedness and gender expression does not fit the gender assigned to them. So they resist the toys and clothes and activities they are ‘supposed’ to enjoy.”

INSISTENT, PERSISTENT, CONSISTENT Crucially, says Addinall, the child’s claim that they are not the sex their parents tell them they are must meet three assessment criteria, as articulated in the standards of care guidelines for transgender children drawn up by the World Professional Association for Transgender Health (WPATH): their distress with their assigned gender must be insistent, persistent and consistent.

But if your child is unhappy, and is insistent, persistent and consistent about actually being a boy (or a girl), it’s time to listen. “Gender identity is unalterably established by two or three years of age,” says Addinall, “and it is not uncommon for transgender children to articulate that they are not a boy (or a girl) at three or four years old.”

WPATH’S standards of care recommends that prepubescent children who have been appropriately assessed by a professional should be allowed to socially transition and live as their preferred gender. This means, says Addinall, that they choose a gender-appropriate name and use appropriate pronouns.

When they reach puberty, they can then explore puberty pausing with a paediatric endocrinologist. Surgery is only available to adults over 18.

A NEW ME In Alex’s case, she chose to become known as and referred to as a girl around age four to five. Her parents complied: they found a school where Alex, now in grade 1, could attend as a girl and use the girls’ or unisex bathrooms. “She went in ‘stealth’, meaning only the teachers knew she was a transgirl,” says Jen. “But within days she was asking to tell her friends, so we arranged a meeting with parents and explained our situation.”

Alex’s parents have applied for a name change in her birth certificate at Home Affairs. “Changing the gender in her birth certificate is a bit more complicated,” says Jen. South African ID numbers have a sex marker, and authorities need to see supporting letters from doctors to change the sex, so changing Alex’s ID “will probably only be possible once she has hormonal treatment in her teens, but is at least legally possible in South Africa.”

“Alex is always free to change her mind, but every day it becomes clearer that she is a girl and that isn’t going to change any time soon, just as it hasn’t for me or anyone else I know.” YB