Editor’s Note: Anna K. Swartz works on neuroethics and mental illness. Here, she reflects on the conceptual and ethical pitfalls of attempting to use brain scans to determine whether children who report being trans are “really” trans.

In late May 2018, researchers made international headlines with a pair of new experiments suggesting that the brains of transgender people more closely resemble the brains of the gender they identify with than the gender implied by their sex assigned at birth. The research, led by Dr. Julie Bakker of the University of Liège in Belgium, assessed the neural activation patterns and brain structure of 160 young trans kids with a diagnosis of gender dysphoria (GD)—the discomfort associated with feeling that the parts of one’s body do not fit with their gender identity.

Participants—adolescent and prepubescent children with GD—were exposed to androstadienone, a pheromone thought to evoke gender-specific activity in the hypothalamus of heterosexual, cis-gender women. Each participant’s brain was imaged using MRI, and the team combined this information to get a clearer picture of the neural response to the stimulus.

Researchers found that both adolescent trans girls and boys showed evidence of hypothalamic response, providing support for the idea that trans brains are more similar to the brains of their desired gender identity than the gender associated with their natal sex. According to the researchers, this experiment “supports the hypothesis of a sex-atypical brain differentiation in these individuals.”

These findings, presented recently at the European Society for Endocrinology annual meeting, closely relate to Baaker’s co-authored 2017 publication, “Brain Functional Connectivity Patterns in Children and Adolescents with Gender Dysphoria: Sex Atypical or Not?” In this paper, Bakker and her team examined the brain scans of a small sample of trans people—mostly adolescent and prepubertal children—and classified them as “sex typical,” “sex atypical,” or “GD-specific.” Here, “sex atypical” refers to assigned sex. Trans girls were revealed to have “sex atypical” FC (functional connectivity) patterns if their scans looked like those of cis girls. Similarly, trans boys were identified as “sex atypical” FC if their MR images resembled those of cis boys’ brains. Interestingly, researchers examining FC in the brains of prepubertal children found no differences between any group of children: trans, cis, or binary—all displayed similar FC in all networks.

These studies join a growing body of research pointing to the biological origins of sexual orientation and gender identity. These findings often find favor among many in the queer community. Just as with sexuality, there are a lot of people who would really love to find a biological cause for being trans.

On the one hand, it isn’t difficult to see why such research is embraced as it affirms the humanity of so many who struggle every day for recognition and the freedom to live authentically in an repulsively violent and transphobic world. This research validates the legitimacy of trans identities in same way that biological evidence for sexual orientation speaks to and matches many of our personal experiences of being gay or bisexual or trans in the sense that these things feel like they are a deep, innate, unchangeable aspect of who we are. It’s a belief that meets our social, personal, political, and cultural needs, and a belief that feels true. The latest research finding that gender identity is determined in early childhood only bolsters this sense of legitimacy and naturalness.

 

But as Samantha Allen points out, biological arguments linking gender identity to birth aren’t likely to sway someone who is determined to hate you. On its own, this research doesn’t ameliorate hate, violence, or bigotry directed at trans people. Even if brain scans could provide some indication that a child may be transgender, there’s no guarantee that the child’s parents would actually be supportive of that identity. It could well lead to more kids being subjected to harmful conversion therapy that tries to correct their gender or that somehow prevents them from being transgender, even though there’s no scientific basis for doing so. It’s naive to think that any scientific research can produce a more just and safer world for marginalized people to freely while having their humanity respected.

Indeed, there are many good reasons why we should be cautious of any scientific studies directed by researchers who either seek or claim to have found the cause—or worse, cure—for the experience of being trans. Even research designed to affirm the humanity of trans people and support their healthcare access must always be situated in a broader socio-political context. What are the implications of research findings that claim to objectively detect the subjective experience of GD and transness through neuroimaging technology?

Bakker has suggested that the latest findings on trans children is especially significant in that brain scans might someday be used as a tool to inform how children with GD are diagnosed and treated. “The earlier it [being transgender] is detected, the better the outcome of treatment,” she told Newsweek.

While I agree that the early medical intervention and support for children who suffer from GD is always best, it is deeply worrisome that we should be looking to a wildly expensive and inaccessible MRI for an “objective” diagnosis of GD when the much more human thing would be to ask kids themselves. It’s likely that young children (and probably many adults) are unable to articulate what gender dysphoria “feels like” but surely it also cannot be reduced to a physiological measure either.

It also doesn’t take too many leaps to see how the use of MRIs might impose and reinforce a socially expected sex/gender dyad by attempting to prevent the existence of individuals whose sex/gender alignment is deemed inappropriate. The ideology is not a product of medical advances; rather the technological and medical advances are products of this ideology.
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In other words, we should be concerned about such neuroscientific evidence of gendered differences being used as justification for denying trans people access to transition related resources and support and as a tool to pathologize how they want to exist in the world.

Indeed, there is a long history of “gatekeeping” in transgender healthcare that continues today. In this most common—and arguably disturbing—model of healthcare, doctors and healthcare serve as arbiters of who can and cannot claim trans identity by setting certain goalposts that trans people have to meet before they’re allowed to access transition related medical care. Trans people must adhere to the criteria set forth by medical establishments governing their transition, which include therapy and diagnosis of GD by a mental health professional, mandatory waiting periods, and “real life experience” without desired medical assistance that can stretch over years.

 

The current relationship between trans people and the medical/psychological establishments remains contentious. According to a landmark study of nearly 28,000 people released in 2016, one-third of trans people reported negative healthcare experience in the previous year such as verbal harassment, refusal of treatment, or the need to teach their doctors about trans healthcare. Some 40 percent have attempted suicide, almost nine times the rate for the general population. Because trans people have a lot of trauma related to denial of access to those interventions, the nightmare scenario of people being shut out of treatment because a brain scan “proves” they don’t have GD is a live concern.

This brings me back to questions concerning the validity, usefulness, and practical applicability of scientific research that claims gender identity is primarily the product of neurobiology. In reality, nothing about the brain is black and white; brains are varied, complex, and malleable, and not all carry typical characteristics we might expect to see.

In the published conference abstract announcing their findings, Bakker and colleagues also examined the brain structure of trans participants, including both regional gray matter (GM) and white matter (WM) microstructure. Such brain organization research suggest that men and women literally have different kinds of gray matter (due to hormones) resulting in different brains. “Although more research is needed, we now have evidence that sexual differentiation of the brain differs in young people with GD, as they show functional brain characteristics that are typical of their desired gender,” Bakker told the UK’s Telegraph.

However, being trans does not necessarily limit gender identity to being “male” or “female” and individuals may not feel exclusively either way. While the categories of “female” and “male” have utility, they should not be considered strictly dichotomous and mutually exclusive. Given what we know about the variability of sex and fluidity of gender, both the 2017 study and the 2018 presentation fail to include, much less acknowledge, the full scope of trans identities including those that are non-binary, genderfluid, and genderqueer. This leaves out a significant and growing portion of the trans youth population.

The researchers also neglect well-established evidence that the brain and the neuroendocrine system are not stable foundations from which behavior and cognition emerge but develop and change in a constant dialectic with social and material inputs, including an individual’s own behavior, learning, and mood states. This presents a bit of a chicken-or-egg-problem about what these research findings are actually telling us. However, can we be sure that GD is the result of this difference in structure and function or is it the cause? Taking into account neuroplasticity as well as the fact that all trans children participants were already receiving care for GD, an alternative conclusion to draw would be that trans children receiving help and support go on to develop brain structures and activity patterns associated with their true gender.

I feel confident saying that we can safely reject research that is designed to measure trans people along cis standards and judge where they fall. These studies ultimately do a disservice to the binary among us and completely erases everyone else.

What does this all mean?

First, and loudest: the legitimacy of trans identities cannot hinge on whether trans brains look like cis brains.

What else? Absolutely zero of this is clinically useful in reality. The truth is, we can already diagnose trans kinds for free by informing them about trans identities, not stigmatizing them, and just listening and asking them. Do we need brain scans to confirm whether straight people are straight, or can we just ask them? We shouldn’t have to validate ourselves with biology, and nobody should have to prove that they’re “really” a certain gender in order to be treated like a person.