Biological Maleness And Femaleness Is Referred To As Gender Reassignment

Bernadette Tobin is Director of the Plunkett Centre for Ethics, a joint centre of St. Vincent's Hospital, Sydney, and Australian Catholic University.

In Amoris Laetitia, the Apostolic Exhortation published last year, Pope Francis rejected any theory of gender that "denies the difference and the reciprocity in nature of a man and a woman."

Quoting the Catechism of the Church, he said that "biological sex and the socio-cultural role of sex (gender) can be distinguished but not separated."

Educational programmes and laws that promote a personal identity and emotional intimacy radically separated from the biological difference between male and female are intended, he thinks, to undermine the anthropological basis of the family.

The Pope acknowledges that the question of how the Church responds to transgender Catholics poses a "human" problem, one which needs resolution. But, he insists, "always with the mercy of God, within the truth."

As Pope, he has often said that the Church must not abandon transgender people, that it should welcome and embrace everyone:

"It is one thing for a person to have this tendency, this option, and even change sex. But it is another thing to teach it, gender theory, in schools along these lines in order to change mentality. I call this ideological colonisation."

What is the approach rejected by Francis? In what follows I will attempt to summarize the main elements of the approach to sex and gender which he rejects as not "truthful." In so doing, I will distinguish two versions of this approach. I will then contrast that approach (and its two versions) with another approach which does affirm "difference and reciprocity in the nature of a man and a woman." I will call the first approach, which the Pope rejects, "the gender-is-culturally-determined" view and the second approach, which he endorses, the "sex-and-gender-are-coordinate" view.

I should say in advance that, as these two approaches are not entirely different from each other, it is important to be clear about what they have in common and where they differ. This is complicated, in particular because of the variety of versions of each approach, and because there may be important differences between each variety of the same approach.

Basic definitions

The terms male and female refer to the biological categories which apply to species which reproduce sexually. Thus human beings, most animals and many plants are sexually male or female. Apart from very rare case of people born with a congenital deformity such that their maleness or femaleness is indeterminate (or "ambiguous"), every human being is male or female.

The terms masculine and feminine refer to gender - that is, to the ways in which maleness and femaleness are expressed in the development of the basic biological difference between males and females. Just what these forms of expression are depends, in large part, on the beliefs and attitudes of the people who influence that development; parents, wider family, school, the surrounding culture.

Indeed, the expressions of masculinity and femininity can be significantly influenced by the individual's culture, for better or worse. Cultures have their own characteristic determinations of the kind of behaviour that is appropriate to males and to females. Some cultures have very narrow determinations of what is masculine and what is feminine (often referred to as "stereotypes"): these determinations can rigidly structure a child's earliest experiences. Other cultures have more flexible determinations of what is masculine and feminine: they thus leave the child's earliest experiences, and expressions, of what is masculine or feminine more open to variety.

The gender-is-culturally-determined view

This view may be summarized as follows. Sex and gender are two different things. Human beings are by nature sexually dimorphic - that is, biologically either male or female. Apart from a rare few whose biological sex is "ambiguous," every human being is either male or female.

Gender is entirely different. Whereas biological sex is discernible at birth (and nowadays, even earlier), gender is a product of socialization. The process of socialization begins at birth at which time gender is "assigned." Children born with male genitalia are assigned to the masculine gender and are then socialized into masculine ways of thinking and acting: to play with trucks, action figures, footballs and so on. Children born with female genitalia are assigned to the feminine gender and brought up and socialized, into feminine ways of thinking and acting: to play with dolls, dresses, makeup and so on.

The best-known version of the "gender-is-culturally-determined" view is associated with some forms of feminism. Indeed, according to a so-called "radical" form of feminism, gender is the label for the process by which societies and cultures assign superior and inferior status to men and women respectively. At birth, there begins a process of socialization that both prescribes (requires) and proscribes (prohibits) the behaviour ("roles") appropriate to people of each biological sex. Males are taught to think they are superior to females: from birth, males are encouraged to be aggressive and assertive, to exploit their inferiors (females), and to see this as "natural." Females are taught to think they are inferior to males: from birth, females are encouraged to be weak and passive, to conform to their exploitation by men, and to see this as "natural."

Of course, individual males and females may vary about how they feel about the constraints that gender roles assign to them: some may rail against the constraints, some may acquiesce in them, some may actively endorse them. But, according to radical feminism, the key thing is that gender-socialization always and everywhere assigns to women an inferior status.

A more recent version of the view that "gender-is-culturally-determined" - called a transgenderist view - says that gender is not merely "assigned" (not discerned) at birth but is subject to change, more or less at will. It claims that something which it calls "gender identity" is ultimately an entirely personal matter. It is the feeling which a person has about his or her personal self (or "identity"). It is something that no one else can assess or judge (or, in the language of philosophy, it is "unfalsifiable"). It's a feeling the person has about something "innate" in them, something which encompasses their gender. And it is fluid. Though it is not entirely clear what "gender is fluid" means (it must be more than "boys can choose to dress like girls" - and vice versa - for that is uncontentious), fluidity underlies the idea of smoothness and ease of transition from one way of feeling about oneself (as masculine) to another (feminine) or vice versa.

Given that an individual's "gender identity" is sacrosanct, something that ought to be believed and respected by others without question, so too must any changes in that feeling. Gender is a choice.

On this view, since gender is to be understood as a personal experience of oneself, it follows that the category "woman" includes not only those who were born with female biological features (the relevant sex organs and hormones) but also anyone who, though he was born with male biological features, feels that he is a woman. Such a person is sometimes described as a "gender non-conforming male" or a "trans." And the converse. The category of "man" includes not only those who were born with male biological features (the relevant sex organs and hormones) but also anyone who, though she was born with female biological features, feels that she is a man. Such a person is sometimes described as a "gender non-conforming female" or a "trans."

One more pair of linguistic labels found in the "gender-is-culturally-determined" view may be helpful. Trans is a Latin prefix meaning "on the opposite side of" or "on the other side of." Its opposite is the Latin prefix cis meaning "on the same side as." Thus a person who feels that his (or her) gender does not match his (or her) biological sex is said to be transgender, and a person who feels that his (or her) gender does match his (or her) biological sex is said to be cisgender. Both terms rely on the ideas that that sex and gender are two entirely different things and that gender is assigned, not discovered. That said, different versions of this approach have different ideas about who does the assigning. At birth, it's likely to be the parents. Later on, it might be the individual (child) himself or herself.

This view of sex and gender is underwritten by, and in turn underwrites, a radical separation between body on the one hand and mind/feelings/attitudes on the other. Sex is a matter of the body, gender is a matter of psyche or mind or feeling. The real "person" is the mind or psyche, and the body is merely its vehicle. In this regard, transgenderism is a modern expression of an idea that has been around for a long time: the idea that human beings are non-bodily "persons."

There are many varieties of the transgenderist version of the "gender-is-culturally-determined" approach. What they all have in common is the idea that, whether the individual identifies as cisgender or transgender, that person's feelings about their "gender identity" must be believed and respected by others.

Given this view of gender "identity" it is no surprise that there are controversies about what constitutes desirable public policy. For instance, a case which will come before the United States Supreme Court sometime in the near future will decide whether it is unlawful in that country for schools to exclude from places (such as girls' school toilets) gender non-conforming males. In Australia it has recently be proposed that "gender identity" should become a "protected attribute" under anti-discrimination law (as indeed it has in several jurisdictions around the world).

Why call both the radical feminist view and the transgenderist view versions of the same "gender-is-culturally-determined" approach? The reason is that both of these approaches take gender to be nothing other than a cultural artefact. The radical feminist view claims that cultures always and everywhere teach the superiority of the male and the inferiority of the female, and that these ways of thinking determine how masculinity and femininity are expressed in human development. The transgenderist view takes a popular idea from contemporary Western culture - that is, that what ultimately matters about human beings are their feelings and conscious experiences more generally, and makes this the foundation for its theory of personal identity. If I feel that I am an X, then I am an X, and should be respected and treated as an X.

The sex-and-gender-are-coordinated view

The "sex-and-gender-are-coordinated" approach is the more traditional view. Though it is sometimes denigrated as "religious" because it is endorsed in the Judeo-Christian tradition, it does not depend for its cogency on any proposition which could be known only by supernatural revelation. Indeed, it draws on some ideas about men and women that originate in Greek philosophy. So it might just as well be described as a "metaphysical" view of sex and gender.

There are four key features of this view:

  1. Though the term "sex" can be used to point to matters of biology and the term "gender" can be used to point to expressions of human development, maleness and femaleness are not merely a matter of sex organs and hormones. Human beings are male or female through and through. Maleness and femaleness are characteristics of the dynamic whole - body and soul - which is a human being. However, just as the realities of dawn and dusk do not rule out the basic difference between day and night, so too the idea that there are basically two different patterns of human biology and two different patterns of human development does not rule out the possibility of borderline cases in both patterns. Some people - a very rare few - are born with deformities of their sexual organs such that it is hard if not impossible to determine their biological sex. Some people develop gender dysphoria - that is, a distress, which might be mild or moderate or intense, at feeling a mismatch between their biological sex and their feelings about their gender.
  2. "Soul" (the Greeks called it psyche) is that which makes a living thing what it is; a plant or an animal or a human being. (Psyche is thus sometimes translated as "spirit" or even "mind.") It's not some immaterial substance separate from, but residing in, the body. Rather, as Aristotle said, it is the "form" of the living thing (that which makes it what it is); in the case of humans, it is the psyche which makes us beings with capacities for thought and deliberation and choice. Just as a person is "alive" all over, so a person is "en-souled" in every fibre of their body. That is why (for the most part) a person's gender is coordinated with their sex - that is, with their being a living human man or woman. So, on this view of sex and gender, though it is possible surgically to change one's sex organs, strictly speaking it is not possible to change one's sex as this is constituted at the genetic level. Likewise, though it is possible to change one's gender, in the sense of how a person presents themselves to others, such a change does not occur "deeply enough" to change the person's being a man or a woman. To actually change one's sex or one's gender would be to change to become someone else.
  3. Men and women are equal in worth and in inherent dignity. This idea, found in the Jewish Bible, that men and women are "image bearers of God," is intended to convey two things about human beings. First, men and women are radically different from the rest of creation. Yes, they are animals, but animals of a special kind: what Aristotle called "rational," not brute, animals. Second, men and women have a unique status in creation: they are radically equal in worth and inherent dignity. Jesus himself, who said little about sex, treated women as much as men as his "disciples." St. Paul was later to put the equality point in a way which was intended to undermine some of the deepest cultural conventions of his day: "There is neither Jew nor Gentile, neither slave nor free, nor is there male and female, for you are all one in Christ Jesus" (Galatians 3:28). The early Christian church used its commitment to the equality in worth and inherent dignity of men and women to challenge the conventions of the day; for instance, to insist, counter-culturally, that a valid marriage required the free consent of both the man and the woman. Of course, if men and women are equal in worth and inherent dignity, it follows that men and women ought to be recognized as, and treated as, such. That said, like just about every institution and culture in history, the church's attitude to, and treatment of, women has often enough failed to live up to this view of human equality.
  4. Men and women are complementary - that is, suitable partners for each other (Genesis 1:27-28; 2:18). This is obvious with respect to reproduction and, given the natural patterns of attachment of parents to their children and children to their parents, with respect to child-rearing and care of one's family. But it goes deeper and wider than that. That said, both friendships with, and attractions to, members of the same sex are perfectly at home with this view of the complementarity (or to use Pope Francis's word, "reciprocity") of men and women. Reciprocity is a claim both about the nature of the relationship between men and women and a standard by which to judge actual relations, a standard by which to judge cultural conventions as to what is masculine and feminine. It is obvious that cultures can be more or less adequate on this matter. Female genital mutilation is a striking example of a culture getting it profoundly wrong. But so too, in less wicked ways, do cultures which deny women opportunities for education, recreation and political involvement and for assertions of individual freedom of thought and movement and expression. Our own Australian culture has recently made great strides in challenging and correcting cultural conventions in this regard. But threats to the recognition of the equality in worth and inherent dignity of all human beings are to be found everywhere. Role-assumptions can become very static and thus very limiting. So this is always a matter for reflection and revision.

What was the Pope thinking?

At World Youth Day last year, the very same man who insisted that the Church must not abandon transgender people, that it should welcome and embrace them (including as they undergo treatment), spoke with evident feeling against the "ideology" of gender. Why? I can only speculate.

Recall what he rejected in Amoris Laetitia: any theory of gender that "denies the difference and the reciprocity in nature of a man and a woman."

So I wonder whether what moved him to speak with such feeling about teaching children that gender is a matter for choice was simply his view that they are being taught something that is false. Or perhaps what moved him was a suspicion that transgenderist programs are intended to undermine the "anthropological basis" of the family.

Or perhaps what moved him was the reasonable fear that fostering a view of personal identity as entirely a construction of the individual may itself have contributed to the substantial increase, over the last few years, in the numbers of young people who suffer from gender dysphoria.

Bernadette Tobin is Director of the Plunkett Centre for Ethics, a joint centre of St. Vincent's Hospital, Sydney, and Australian Catholic University.

1. Vance SR, Jr, Ehrensaft D, Rosenthal SM. Psychological and medical care of gender nonconforming youth. Pediatrics. 2014;134:1184–1192.[PubMed]

2. American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 5th ed. Arlington (VA): American Psychiatric Association Publishing; 2013.

3. Coleman E, Bockting W, Botzer M, Cohen-Kettenis P, DeCuypere G, Feldman J, et al. Standards of care for the health of transsexual, transgender, and gender-nonconforming people, version 7. Int J Transgend. 2012;13:165–232.

4. Hembree WC, Cohen-Kettenis P, Delemarre-van de Waal HA, Gooren LJ, Meyer WJ, 3rd, Spack NP, et al. Endocrine treatment of transsexual persons: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab. 2009;94:3132–3154.[PubMed]

5. Meyer-Bahlburg HF. Sex steroids and variants of gender identity. Endocrinol Metab Clin North Am. 2013;42:435–452.[PubMed]

6. Sherer I, Baum J, Ehrensaft D, Rosenthal SM. Affirming gender: caring for gender atypical children and adolescents. Contemp Pediatr. 2015;32:16–19.

7. Drummond KD, Bradley SJ, Peterson-Badali M, Zucker KJ. A follow-up study of girls with gender identity disorder. Dev Psychol. 2008;44:34–45.[PubMed]

8. Wallien MS, Cohen-Kettenis PT. Psychosexual outcome of gender-dysphoric children. J Am Acad Child Adolesc Psychiatry. 2008;47:1413–1423.[PubMed]

9. Zucker KJ, Bradley SJ, Owen-Anderson A, Kibblewhite SJ, Cantor JM. Is gender identity disorder in adolescents coming out of the closet? J Sex Marital Ther. 2008;34:287–290.[PubMed]

10. de Vries AL, Cohen-Kettenis PT. Clinical management of gender dysphoria in children and adolescents: the Dutch approach. J Homosex. 2012;59:301–320.[PubMed]

11. Spack NP, Edwards-Leeper L, Feldman HA, Leibowitz S, Mandel F, Diamond DA, et al. Children and adolescents with gender identity disorder referred to a pediatric medical center. Pediatrics. 2012;129:418–425.[PubMed]

12. Sherer I, Rosenthal SM, Ehrensaft D, Baum J. Child and adolescent gender center: a multidisciplinary collaboration to improve the lives of gender nonconforming children and teens. Pediatr Rev. 2012;33:273–275.[PubMed]

13. Conron KJ, Scott G, Stowell GS, Landers SJ. Transgender health in Massachusetts: results from a household probability sample of adults. Am J Public Health. 2012;102:118–122.[PMC free article][PubMed]

14. Reisner SL, Vetters R, Leclerc M, Zaslow S, Wolfrum S, Shumer D, et al. Mental health of transgender youth in care at an adolescent urban community health center: a matched retrospective cohort study. J Adolesc Health. 2015;56:274–279.[PMC free article][PubMed]

15. Travers R, Bauer G, Pyne J, Bradley K, for the Trans PULSE Project. Gale L, et al. Impacts of strong parental support for trans youth: a report prepared for Children’S Aid Society of Toronto and Delisle Youth Services. Trans Pulse. 2012 Oct 02;

16. Rosenthal SM. Approach to the patient: transgender youth: endocrine considerations. J Clin Endocrinol Metab. 2014;99:4379–4389.[PubMed]

17. Berenbaum SA, Bailey JM. Effects on gender identity of prenatal androgens and genital appearance: evidence from girls with congenital adrenal hyperplasia. J Clin Endocrinol Metab. 2003;88:1102–1106.[PubMed]

18. Dessens AB, Slijper FM, Drop SL. Gender dysphoria and gender change in chromosomal females with congenital adrenal hyperplasia. Arch Sex Behav. 2005;34:389–397.[PubMed]

19. Meyer-Bahlburg HF, Dolezal C, Baker SW, Ehrhardt AA, New MI. Gender development in women with congenital adrenal hyperplasia as a function of disorder severity. Arch Sex Behav. 2006;35:667–684.[PubMed]

20. Frisén L, Nordenström A, Falhammar H, Filipsson H, Holmdahl G, Janson PO, et al. Gender role behavior, sexuality, and psychosocial adaptation in women with congenital adrenal hyperplasia due to CYP21A2 deficiency. J Clin Endocrinol Metab. 2009;94:3432–3439.[PubMed]

21. Meyer-Bahlburg HF, Dolezal C, Baker SW, New MI. Sexual orientation in women with classical or non-classical congenital adrenal hyperplasia as a function of degree of prenatal androgen excess. Arch Sex Behav. 2008;37:85–99.[PubMed]

22. Cohen-Kettenis PT. Gender change in 46,XY persons with 5alpha-reductase-2 deficiency and 17beta-hydroxysteroid dehydrogenase-3 deficiency. Arch Sex Behav. 2005;34:399–410.[PubMed]

23. Imperato-McGinley J, Peterson RE, Gautier T, Sturla E. Androgens and the evolution of male-gender identity among male pseudohermaphrodites with 5alpha-reductase deficiency. N Engl J Med. 1979;300:1233–1237.[PubMed]

24. Rösler A, Silverstein S, Abeliovich D. A (R80Q) mutation in 17 beta-hydroxysteroid dehydrogenase type 3 gene among Arabs of Israel is associated with pseudohermaphroditism in males and normal asymptomatic females. J Clin Endocrinol Metab. 1996;81:1827–1831.[PubMed]

25. Reiner WG, Gearhart JP. Discordant sexual identity in some genetic males with cloacal exstrophy assigned to female sex at birth. N Engl J Med. 2004;350:333–341.[PMC free article][PubMed]

26. Meyer-Bahlburg HF. Gender identity outcome in female-raised 46,XY persons with penile agenesis, cloacal exstrophy of the bladder, or penile ablation. Arch Sex Behav. 2005;34:423–438.[PubMed]

27. T'Sjoen G, De Cuypere G, Monstrey S, Hoebeke P, Freedman FK, Appari M, et al. Male gender identity in complete androgen insensitivity syndrome. Arch Sex Behav. 2011;40:635–638.[PubMed]

28. Hyde C, Kenna JC. A male MZ twin pair, concordant for transsexualism, discordant for schizophrenia. Acta Psychiatr Scand. 1977;56:265–275.[PubMed]

29. Green R. Family cooccurrence of "gender dysphoria": ten sibling or parent-child pairs. Arch Sex Behav. 2000;29:499–507.[PubMed]

30. Coolidge FL, Thede LL, Young SE. The heritability of gender identity disorder in a child and adolescent twin sample. Behav Genet. 2002;32:251–257.[PubMed]

31. Heylens G, De Cuypere G, Zucker KJ, Schelfaut C, Elaut E, Vanden Bossche H, et al. Gender identity disorder in twins: a review of the case report literature. J Sex Med. 2012;9:751–757.[PubMed]

32. Henningsson S, Westberg L, Nilsson S, Lundström B, Ekselius L, Bodlund O, et al. Sex steroid-related genes and male-to-female transsexualism. Psychoneuroendocrinology. 2005;30:657–664.[PubMed]

33. Hare L, Bernard P, Sánchez FJ, Baird PN, Vilain E, Kennedy T, et al. Androgen receptor repeat length polymorphism associated with male-to-female transsexualism. Biol Psychiatry. 2009;65:93–96.[PMC free article][PubMed]

34. Ujike H, Otani K, Nakatsuka M, Ishii K, Sasaki A, Oishi T, et al. Association study of gender identity disorder and sex hormone-related genes. Prog Neuropsychopharmacol Biol Psychiatry. 2009;33:1241–1244.[PubMed]

35. Bentz EK, Hefler LA, Kaufmann U, Huber JC, Kolbus A, Tempfer CB. A polymorphism of the CYP17 gene related to sex steroid metabolism is associated with female-to-male but not male-to-female transsexualism. Fertil Steril. 2008;90:56–59.[PubMed]

36. Hoekzema E, Schagen SE, Kreukels BP, Veltman DJ, Cohen-Kettenis PT, Delemarre-van de, et al. Regional volumes and spatial volumetric distribution of gray matter in the gender dysphoric brain. Psychoneuroendocrinology. 2015;55:59–71.[PubMed]

37. Zucker KJ. On the "natural history" of gender identity disorder in children. J Am Acad Child Adolesc Psychiatry. 2008;47:1361–1363.[PubMed]

38. Steensma TD, McGuire JK, Kreukels BP, Beekman AJ, Cohen-Kettenis PT. Factors associated with desistence and persistence of childhood gender dysphoria: a quantitative follow-up study. J Am Acad Child Adolesc Psychiatry. 2013;52:582–590.[PubMed]

39. Zucker KJ, Wood H, Singh D, Bradley SJ. A developmental, biopsychosocial model for the treatment of children with gender identity disorder. J Homosex. 2012;59:369–397.[PubMed]

40. Hidalgo MA, Ehrensaft D, Tishelman AC, Clark LF, Garofalo R, Rosenthal SM, et al. The gender affirmative model: what we know and what we aim to learn. Hum Dev. 2013;56:285–290.

41. Cohen-Kettenis PT, Delemarre-van de Waal HA, Gooren LJ. The treatment of adolescent transsexuals: changing insights. J Sex Med. 2008;5:1892–1897.[PubMed]

42. de Vries AL, Noens IL, Cohen-Kettenis PT, van Berckelaer-Onnes IA, Doreleijers TA. Autism spectrum disorders in gender dysphoric children and adolescents. J Autism Dev Disord. 2010;40:930–936.[PMC free article][PubMed]

43. Strang JF, Kenworthy L, Dominska A, Sokoloff J, Kenealy LE, Berl M, et al. Increased gender variance in autism spectrum disorders and attention deficit hyperactivity disorder. Arch Sex Behav. 2014;43:1525–1533.[PubMed]

44. Cohen-Kettenis PT, van Goozen SH. Pubertal delay as an aid in diagnosis and treatment of a transsexual adolescent. Eur Child Adolesc Psychiatry. 1998;7:246–248.[PubMed]

45. Delemarre-van de Waal HA, Cohen-Kettenis PT. Clinical management of gender identity disorder in adolescents: a protocol on psychological and paediatric endocrinology aspects. Eur J Endocrinol. 2006;155:S131–S137.

46. de Vries AL, Steensma TD, Doreleijers TA, Cohen-Kettenis PT. Puberty suppression in adolescents with gender identity disorder: a prospective follow-up study. J Sex Med. 2011;8:2276–2283.[PubMed]

47. Cohen-Kettenis PT, Schagen SE, Steensma TD, de Vries AL, Delemarre-van de Waal HA. Puberty suppression in a gender-dysphoric adolescent: a 22-year follow-up. Arch Sex Behav. 2011;40:843–847.[PMC free article][PubMed]

48. de Vries AL, McGuire JK, Steensma TD, Wagenaar EC, Doreleijers TA, Cohen-Kettenis PT. Young adult psychological outcome after puberty suppression and gender reassignment. Pediatrics. 2014;134:696–704.[PubMed]

49. Klink D, Caris M, Heijboer A, van Trotsenburg M, Rotteveel J. Bone mass in young adulthood following gonadotropin-releasing hormone analog treatment and cross-sex hormone treatment in adolescents with gender dysphoria. J Clin Endocrinol Metab. 2015;100:E270–E275.[PubMed]

50. Sato T, Katagiri K, Gohbara A, Inoue K, Ogonuki N, Ogura A, et al. In vitro production of functional sperm in cultured neonatal mouse testes. Nature. 2011;471:504–507.[PubMed]

51. Yokonishi T, Sato T, Komeya M, Katagiri K, Kubota Y, Nakabayashi K, et al. Offspring production with sperm grown in vitro from cryopreserved testis tissues. Nat Commun. 2014;5:4320.[PubMed]

52. Staphorsius AS, Kreukels BP, Cohen-Kettenis PT, Veltman DJ, Burke SM, Schagen SE, et al. Puberty suppression and executive functioning: an fMRI-study in adolescents with gender dysphoria. Psychoneuroendocrinology. 2015;56:190–199.[PubMed]

53. Toorians AW, Thomassen MC, Zweegman S, Magdeleyns EJ, Tans G, Gooren LJ, et al. Venous thrombosis and changes of hemostatic variables during cross-sex hormone treatment in transsexual people. J Clin Endocrinol Metab. 2003;88:5723–5729.[PubMed]

54. Asscheman H, Giltay EJ, Megens JA, de Ronde WP, van Trotsenburg MA, Gooren LJ. A long-term follow-up study of mortality in transsexuals receiving treatment with cross-sex hormones. Eur J Endocrinol. 2011;164:635–642.[PubMed]

55. Drescher J, Byne W. Gender dysphoric/gender variant (GD/GV) children and adolescents: summarizing what we know and what we have yet to learn. J Homosex. 2012;59:501–510.[PubMed]

56. Vance SR, Jr, Halpern-Felsher BL, Rosenthal SM. Health care providers' comfort with and barriers to care of transgender youth. J Adolesc Health. 2015;56:251–253.[PubMed]


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