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The New Girl in School: Transgender Surgery at 18

Rebirth of a transgender teenager, as katherine boone, 18, recovered from gender reassignment surgery, she and her family talked about what they went through..

It was not easy. For days afterward, she had dry heaves. She lost weight from her already frail frame. She did not seem empowered; she seemed regressed. “I just want to hold Emma,” she said in her darkened room at the bed and breakfast in New Hope, Pa., run by the doctor who performed the surgery in a hospital nearby. Emma is her black and white cat, at home outside Syracuse, N.Y., 200 miles away. Her childlike reaction was, perhaps, not surprising. Kat, whose side-parted hair was dyed fire engine red, is just 18, and about to graduate from high school. It is a transgender moment. President Obama was hailed just for saying the word “transgender” in his State of the Union speech this year, in a list of people who should not be discriminated against. They are characters in popular TV shows. Bruce Jenner’s transition from male sex symbol to a comely female named Caitlyn has elevated him back to his public profile as a gold-medal decathlete at the 1976 Summer Olympics.

By Anemona Hartocollis

June 16, 2015

In a cozy cottage decorated with butterflies to symbolize transformation, Katherine Boone was recovering in April from the operation that had changed her, in the most intimate part of her body, from a biological male into a female.

It was not easy. She retched for days afterward. She could hardly eat. She did not seem empowered; she seemed regressed.

“I just want to hold Emma,” she said in her darkened room at the bed-and-breakfast in New Hope, Pa., run by the doctor who performed the operation in a hospital nearby. Emma is her black and white cat, at her home outside Syracuse in central New York State, 250 miles away.

Her childlike reaction was, perhaps, not surprising. Kat, whose side-parted hair was dyed a sassy red, is just 18, and about to graduate from high school.

It is a transgender moment. President Obama was hailed just for saying the word “transgender” in his State of the Union address this year, in a list of people who should not be discriminated against. They are characters in popular television shows. Bruce Jenner’s transition from male sex symbol to a comely female named Caitlyn has elevated her back to her public profile as a gold-medal decathlete at the 1976 Summer Olympics.

With growing tolerance, the question is no longer whether gender reassignment is an option but rather how young should it begin.

No law prohibits minors from receiving sex-change hormones or even surgery, but insurers, both private and public, have generally refused to extend coverage for these procedures to those under 18. In March, New York’s Medicaid drew a line at that age, and at 21 for some procedures.

But the number of teenagers going through gender reassignment has been growing amid wider acceptance of transgender identity, more parental comfort with the treatment and the emergence of a number of willing practitioners. Now advocates like Empire State Pride Agenda are fighting for coverage at an earlier age, beginning with hormone blockers at the onset of puberty, saying it is more seamless for a teenage boy to transition to becoming an adult woman, for example, if he does not first become a full-bodied man.

“Some of these women are passing, but barely, when they transition at 40 or 50,” said Dr. Irene Sills, an endocrinologist who just retired from a busy practice in the Syracuse area treating transgender children, including Kat. “At 16 or 17, you are going to have such an easier life with this.”

Given that there are no proven biological markers for what is known as gender dysphoria , however, there is no consensus in the medical community on the central question: whether teenagers, habitually trying on new identities and not known for foresight, should be granted an irreversible physical fix for what is still considered a psychological condition.

The debates invoke biology, ideology and emotion. Is gender dysphoria governed by a miswiring of the brain or by genetic coding? How much does it stem from the pressure to fit into society’s boxes — pink and dolls for girls, blue and sports for boys? Has the Internet liberated teenagers like Kat from a narrow view of how they should live their life, or has it seduced them by offering them, for the first time, an answer to their self-searching, an answer they might later choose to reject?

Some experts argue that the earlier the decision is made, the more treacherous, because it is impossible to predict which children will grow up to be transgender and which will not.

“Basically you have clinics working by the seat of the pants, making these decisions, and depending on which clinic you go to, you get a different response,” said Dr. Jack Drescher , a New York City psychiatrist and psychoanalyst who helped develop the latest diagnostic criteria for gender dysphoria.

On the other hand, Dr. Drescher said, “Is it fair to make a child who’s never going to change wait till 16 or 18 to get treatment?”

A Teenager’s Pain

Kat Boone did not fit the stereotype of a girl trapped in a boy’s body.

As a child, she dressed in jeans and shirts, like all the other boys, and her best friend was a boy. She liked to play with cars and slash bad guys in the Legend of Zelda video games. She still shuns dresses, preferring skinny jeans and band T-shirts.

But as a freshman in high school in Cazenovia, N.Y., she became depressed and withdrawn. “I knew that the changes going on with puberty were not me,” Kat said. “I started to really hate my life, myself. I was uncomfortable with my body, my voice, and I just felt like I was really a girl.”

When she discovered the transgender world on the Internet, she had a flash of recognition. “I was reading through some symptoms, not really symptoms, but some of the attributes of it did click,” she recalled.

It took a few months, but one night, she crept into her mother’s room and sat on the bed, crying. When she finally came out with what was bothering her, her mother’s first impulse was to comfort her, holding her hand and saying: “It’s O.K. It’s O.K.”

But inside, Gail Boone was terrified. She had wondered if her son was gay, and that, she says, would have been easier to deal with than a child who wanted to be the opposite sex.

“There’s this fear,” Ms. Boone said, “what is this going to do to my kid, what are people going to think, what are people going to think about me?”

Kat’s father, Andrew, had moved out when she was in fifth grade, and it took a few months for Kat and her mother to find the courage to tell him. Gail Boone had a background in psychology, which helped her understand. Mr. Boone, an operations and project manager, had a harder time, but was brought around for the sake of his child.

He read books about being transgender and raked his memory for clues in Kat’s early childhood, but could not find any. “Maybe she thinks this is the thing, and there’s something else going on,” he remembered thinking. “How do we know?” He wished there were something scientific like a blood test that would give him 100 percent certainty.

Mr. Boone recalls going into “a zombie trance,” a period of mourning for the child he thought he knew. “I was really eating myself up because I couldn’t help this overwhelming feeling as if my child had died,” he said. “But here was my child right in front of me.”

At 16 and a half, after seeing a therapist, Kat began taking estrogen and a blood pressure drug, spironolactone, that is also used to block the actions of testosterone, to help her look more female. In the fall of junior year, she showed up at school wanting to be called Katherine, or Kat, because she likes cats. She does not want anything to do with her birth name, Caden. She also has discovered that she likes girls. “I identify as a lesbian,” she said, though her attractions have not been reciprocated.

It was the cutting that convinced them that if she could not live as a girl, Kat would kill herself. She still has two angry scars on her left forearm. “It became clear to me that this wasn’t a passing phase or some choice or reaction,” Mr. Boone said. “This was truly the basis of what she was.”

Part of what brought her father around was the support network that has sprung up around transgender issues. In Syracuse, it is the Q (for queer or questioning) Center, run by the nonprofit ACR Health .

It is not easy to find. Visitors have to be buzzed in through an unmarked back door in a shabby neighborhood. But inside, it is homey, with a well-appointed library, a kitchen and a meeting room outfitted with beanbag chairs.

A meeting of teenagers in April began with each one declaring a name and pronoun of the day. Their choices were not always intuitively obvious. A young man with a scruffy beard and shaggy hair asked to be called Jackie and with the pronoun “she.”

“One of the nice things a trans person gets to do during transition is pick a new name,” said the facilitator, Mallory Livingston, a lawyer, “assigned male at birth,” now looking feminine in a tight pink camisole, black lace-up boots and miniskirt. “I went with the name of a character from my kids’ favorite movie, a strong female swordsperson.”

But there were hints of the pain the children had to endure. One child was required to use a separate bathroom at school, and a hidden camera was later found there.

Kat told the group that she was looking forward to surgery in six days. They clapped. “I’m scared,” she confessed.

A Young Movement

The ability to alter a child’s gender physically has never been greater.

But the drive to treat children is relatively new. One of the first and biggest hormone programs for young teenagers in the United States is led by a Harvard-affiliated pediatric endocrinologist, Dr. Norman Spack , at Boston Children’s Hospital.

Dr. Spack recalled being at a meeting in Europe about 15 years ago, when he learned that the Dutch were using puberty blockers in transgender early adolescents.

“I was salivating,” he recalled. “I said we had to do this.”

The puberty-blocking protocol gained legitimacy in 2009, when it was endorsed by the Endocrine Society, the leading association of hormone experts, on the recommendation of a task force including Dr. Spack.

The protocol calls for administering puberty-blocking drugs, generally Lupron, an injection, or histrelin, an implant, that are normally used to treat precocious puberty as well as prostate cancer and endometriosis, abnormal growth of uterine tissue.

The theory is that this drug-induced lull from about 12 to 16, sometimes younger, will help teenagers decide if they truly are transgender, without committing to irreversible physical changes. Puberty blockers are reversible. But in practice, some experts warn, once children have “socially transitioned” it is very difficult to go back.

If a psychological evaluation confirms gender dysphoria, teenagers are treated with cross-sex hormones (estrogen for boys, testosterone for girls), so they will, in effect, go through opposite-sex puberty. A consequence of going through the whole protocol is infertility.

The blockers cost thousands of dollars a year, and like all drugs used for transgender treatment, have not been approved by the Food and Drug Administration for that use, though they may be legally prescribed “off label.”

Dr. Spack said his clinic had treated about 200 children since 2007, and less than 20 percent had been covered by insurance. “That’s where the dilemma came in: Who the hell could afford it?” he said.

Doctors say that if children are started on puberty blockers young enough, insurance is less likely to question it. Some doctors have been able to drive the price down to $120 a month by getting the adult implant, which is much cheaper than the pediatric one, from sympathetic urologists and stretching it out over two years instead of just one.

While hormones for minors are sometimes covered by insurance, surgery almost never is. But several doctors said they had performed surgery on minors. Kat’s surgeon, Dr. Christine McGinn, estimated that she had done more than 30 operations on children under 18, about half of them vaginoplasties for biological boys becoming girls, and the other half double mastectomies for girls becoming boys.

“We’re trying to find the sweet spot,” Dr. McGinn said. “The problem is, it’s not an age, it’s a situation.”

Advocates say that extending treatment to teenagers will alleviate depression and suicide. With that in mind, Oregon’s Medicaid began covering the gamut of treatment, regardless of age, in January. Patients as young as 15 do not need parental consent.

The evidence is mixed. A large-scale Swedish study at the Karolinska Institute found that starting about a decade after gender reassignment surgery, transgender people were still more than 19 times as likely to die by suicide as the general population.

Complicating matters, studies suggest that most young children with gender dysphoria eventually lose any desire to change sex, and may grow up to be gay, rather than transgender. Once into adolescence, however, their dysphoria is more likely to stick.

Dr. Paul McHugh , a professor of psychiatry at Johns Hopkins University Medical School and its hospital’s former psychiatrist in chief, is skeptical of the use of surgery for a psychological condition, and even more so for children. “Bruce Jenner — who cares?” said Dr. McHugh, who said he played a role in closing a transgender surgery program at Johns Hopkins about 35 years ago. “He’s a wonderfully successful person. He’s got all kinds of social networks. He’s got plenty of money. No one’s objecting to him if he wants to live as a woman. This is America, be my guest.

“But we’re talking about children with a future ahead of them.”

A New Beginning

Kat went into the surgery on April 7 with high hopes.

Dr. McGinn was far from Cazenovia, in Lower Bucks Hospital in Pennsylvania. But Kat’s parents trusted her not only as a specialist, but also as a role model: She had been a dashing male doctor in the Navy, before becoming a beautiful female doctor in civilian life.

Kat had been accepted at Champlain College in Vermont, where she planned to use her artistic talent (she designed the rose tattoo on her shoulder) to study video game design. Her goal was to start college as a woman. Through luck — a cancellation — they were able to book a date during spring break, when Dr. McGinn’s calendar begins filling up with college-bound patients.

Gail Boone’s insurance plan initially denied coverage for the operation. A customer service agent told her genital reconstructive surgery was allowed only for conditions like birth defects. “You got it,” Ms. Boone retorted.

They prevailed.

It was too late to change some things, like Kat’s tenor voice and facial hair. “I hate my voice,” she said. “I shave.” She chose not to save sperm — to her, a revolting reminder of masculinity — so she cannot have children, the one sacrifice that gave her father a pang.

The operation involved deconstructing her male genitals and repurposing the nerves and skin as female anatomy.

When it was over, Kat developed aspiration pneumonia and had vomiting and dry heaves for days, normal reactions to anesthesia, narcotics and antibiotics, but Dr. McGinn said Kat was hit harder than most.

Before the surgery, she had been impish and playful. Now she buried her nose in her Nintendo 3DS and cracked a rare smile at an old text message consisting entirely of “Meow,” “Meow.”

Her father felt helpless as she refused food and lost about 20 pounds. Dr. McGinn said it was not unusual for patients to become depressed after surgery and compared this to postpartum depression.

Kat was anxious about having enough privacy in college, since her new vagina needs constant care or it will close off like a wound. “The only thing I’m thinking about now is the room situation,” she said.

Six weeks after the operation, she was still so weak that she had to take the elevator at school instead of the stairs.

At her two-month checkup, she had gained back half the weight she had lost, but still looked frail and self-conscious. She treated herself to a new hair color — strawberry blond — for graduation.

Kat said she had “zero regrets.”

But it was clear to all of them that the operation was not a quick fix.

It is not a “yippie, jump up and down fireworks situation,” Mr. Boone said. “It’s a grand relief that something that’s been such a bother to her is finally gone.”

Because of an editing error, an earlier version of this article erroneously attributed a distinction to New York’s Medicaid program. It is not the nation’s largest (the state with the largest Medicaid enrollment is California).

An earlier version of a picture caption with this article misstated the circumstances of Katherine Boone’s suicide threat. She cut herself when she was 17, not 16, and when she had already begun gender reassignment, not before.

How we handle corrections

Susan C. Beachy contributed research.

Photo illustration of photographer's pre and post operative faces

HISTORY & CULTURE

‘This is me, as I am’: A photographer documents her own gender transition

In 2015, Allison Lippy realized who she had always been—and turned her camera on herself to understand her journey as a transgender woman.

It took 27 years for me to realize I was transgender. It took a month or two to decide to physically transition. It took even less time than that to understand that I should document my transformation—for myself and for anyone else who needs to see it.

I should start at the beginning.

Self Portrait of the photographer taken in black and white

Growing up in Baltimore in the 1990s and early 2000s, I wasn’t aware that people could be anything other than the gender they were assigned at birth. There weren't resources or role models available to me at that point to even begin to understand who I was.

However, there were little hints of my queerness, a feeling of being different, something intangible. I never shared nor had the opportunity to explore those feelings until my early 20s. When I was 21, I came across videos of trans women on YouTube talking about their transitions. I would return to the videos periodically to see their updates, which intrigued me. I was telling myself that this was just research for a story that I wanted to do on trans identity. I wasn’t yet ready to confront the truth about myself.

I moved to New York City in 2011. Keeping my mind and body occupied by working in the photo industry distracted me from introspection. In 2015, I was sitting in my therapist’s office when she casually mentioned a person—a celebrity—who had come out as trans. I don’t remember what the context of that conversation was. I don’t think I was even paying particular attention to what she was saying. But I remember thinking, ‘Oh, that’s interesting.’

That throwaway comment was the spark that forced me to stop ignoring what had been burning in my subconscious. When I was at home, alone with my thoughts, I pondered my identity. Asking myself over and over again, ‘Am I trans? Am I a woman?’ I told myself probably not. Then I thought, ‘Maybe?’ I went back and forth, but as the days and then weeks progressed, the answer became clear: ‘Yup, that’s you.’

Finally, I realized I needed to accept who I was.

All the confusion I’d felt made sense; all the puzzle pieces fit for the first time. Everything just fell right into place. Confident and excited, I started moving quickly to make up for lost time.

I came out to my therapist first, just to test the waters, and then to my mother, who gladly was my rock throughout my transition. I’m fortunate that everybody in my life—including my parents, brother and friends—was really accepting.

Fundamentally, I owe my very existence to my trans elders, especially queer Indigenous, Black, Asian, Latinx, and POC people. They were in the streets and in our communities doing the hard work,paving the way for the rest of us to discover and live authentically as ourselves. Trailblazers, like Marsha P. Johnson, Sylvia Rivera, and countless others , stood up and fought for our community in a time when visibility and representation were next to none.

Within a few months of coming out, I started taking hormones—and I began making self-portraits. Turning the camera on myself was a way to understand where I started and where I would end up. As a photographer and someone who didn’t encounter positive images of trans people as a kid, I felt I had a responsibility to tell my story through my own queer perspective.

I don’t intend to be representative of all trans people. Just as there isn’t one way to be human—there isn’t one right way or one wrong way to transition. We each have our own path.

My path happened to be a medical transition. In 2016, I went through facial feminization and gender reassignment surgeries. The facial feminization surgery reconstructed my skull, shaving bone to remove the effects of testosterone. While this might seem extreme, imagine discovering who you truly are and then looking in the mirror and seeing someone else. The surgeries were painful, but the journey to be yourself always includes some pain, sometimes mentally and physically.

It’s difficult to look back at old family photos now. I wish I could have been me earlier. But when I look at photos from early in this project, I see a person who is on a journey to being their true self. And toward the end of the series, there’s a few images where I think: ‘This is me, as I am. I have zero regrets.’

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Interviews : “Forced Gender Reassignment wasn’t really THAT bad…” – An Interview With Travis Ryan (Cattle Decapitation)

Cattle Decapitation – Travis Ryan

A band that brings to light some of the most pressing social and environmental issues of today’s world, through the sheer brutality of their music and who do it extremely well might I add, Cattle Decapitation has undeniably earned their top spot in the world of heavy metal. “Our name – it’s such a crazy irony. When it was created, it was just to be blatant, kind of ridiculous and over the top. The dudes who also play in the band The Locust came up with this really ‘out there’ name but once I came into the band, we sort of morphed it into a metaphor for, the destruction of the human race. People in mass, are often referred to as ‘cattle’ and well, I guess that’s just what we want to project. That the human race is leading itself to destruction.”

It’s been five years since the band have visited our shores and Travis Ryan, vocalist of the band, is alarmed at the immense gap between their tours. “The only thing we have planned for the next year is our Australian Tour and we are really, really looking forward to that. We have great memories of the country and just being there was amazing. For me, one of my favourite memories is obviously going to the koala sanctuary, hanging out with the kangaroos out on the lawn, it was really amazing. It all happened pretty quickly. I spent almost 40 years of my life just wanting to go to Australia, get the Australian experience, I was obsessed with the idea of going there. I tried for years to get the band over there and it was always such a pain in the ass. It still is a pain in the ass! Took us two years. Our last album came out two years ago so we should have been there fucking two years ago!”

But this extended time between tours can only mean one thing – a kick arse setlist! ” We’re bringing our best set that we’ve ever done! It’ll definitely be the longest set we’ve ever done as well. It’s basically going to be the last three records – that’s our favourite stuff to play really. We’ve gone back through our old catalogue and tried pulling songs out and it doesn’t really work. I hate to say it but to the people that want to hear it, we would just rather play the newer stuff. We’re a bit selfish that way I guess but nobody’s really complained so far, so I think we’re good!” I’d be happy watching them perform just their latest album, but the last three – well, holy shit Australia, you better be mosh-ready! “We love getting up in people’s faces and vice versa”, Travis says with glee when talking about the band’s live performances. “That’s the kind of band we are. I think we’re built mostly for clubs and pub shows. I’m not going to say the smaller the better, because with small venues, sometimes, comes shitty equipment and PA’s. We like to sound good when we play live, as good as possible! I guess you could say we shine brighter in the club scene even though festivals are fun to play.”

Cattle Decapitation’s last release in 2015, The Anthropocene Extinction was my album of the year and was a favourite amongst many end of year lists, which honestly comes as no surprise. It was unlike anything the band had done before and reflected in their music. Travis spoke about the most pressing matter in the world that concerns and scares him. “Well, I don’t want to get into politics. Apart from that, it’s honestly the amount of plastic and trash that is present in the world’s oceans making its way from the land. This has been happening for so many years – since the 50’s I guess when the dawn of plastics came into play and we started manufacturing so much. Seeing the amount of waste that is washing up on remote islands, is alarming – these are fragile ecosystems that could create a chain reaction. The same things are happening on land and it all comes back to humans of course. Overpopulation, the sheer density of it all, and no one really knows what to do. This is one big thing that kinda scares me the most.” Musically, this was indeed a standout album from the band’s career and it always amazes me, how, even after so many years, a band can still keep things fresh, unique and in the case of Cattle Decap so completely unorthodox. ” Well we’ve been around for a long time, and I’m not trying to sound all hoity-toity, but as an artist, you get bored of doing the same old kind of thing. You just want to branch out and it’s amazing, having a group of people in the band that are cool with that, trying different things with their respective instruments. When the band started writing more melodic stuff, that really opened the doors for us, especially for me, to try and do something that nobody else was really doing.”

“It all comes to us naturally; I can’t really speak for them, I don’t know how they write – I come in later. For me, it just comes naturally. Honestly, there are things that don’t work. Like, I’ll get in the studio (and this happened on a song on the recent record), and I don’t know what the hell I was hearing before but think to myself that this clearly isn’t working now. So we have to work with the producer and think of ways to do something completely different. The sound dynamic does come to us naturally but to get there, it’s a lot of work. It’s all part of the process. ”

Fifteen minutes wasn’t enough to have a chat with one of my favourite vocalists in metal, but I managed to sneak in a little conversation about the video that YouTube rejected and caught the attention of even the Russian Deep Web. “With that video; for ‘Forced Gender Reassignment’ – it was a curiosity thing. It’s quite literally one of, if not the most brutal, horribly disgusting music video of all time. You couldn’t find it on youtube anywhere but there were reaction videos to it! The funny thing to me is – this has all been done before. Horror movies, snuff shit, disgusting real life stuff on the internet, gore – when you look at all of that stuff, this video wasn’t REALLY that bad. ” Asking Travis to elaborate, he explains, ” There’s a phenomenon that happens when you put music over some horrible visual that immediately repulses people or draws people in…You take a video of a puppy- its just a puppy, you look at a puppy and it’s cute as hell. and you’re like ‘awwww’. and if you go and put Sarah McLachlan’s music over it and all of a sudden, you’re tearing up and crying because the pressing melancholy music of this video is going over this little puppy.” But wait, there’s more to this! “All of a sudden it takes a completely different turn you put death metal music over something like that, it’s glorification of whatever is happening on the screen. It wasn’t coming from the gore for the sake of gore standpoint, that’s why it was controversial and it gets talked about.”

When chatting with bands that have been around for years together, I love getting their opinion on certain aspects of this industry and the scene – one of them being the insane number of genres and labels that now exist. Travis had a lot to say about it too. “We have to remember – these are mostly kids coming up with this shit and, they’ll figure it out. Or not. Fuck them anyway. I’m honestly torn on it because I think it’s stupid to label a band. Every single band that comes out now is like, ” WE ARE …..” and then there’s a string of adjectives following that. It’s all just unnecessary. Like, I call us extreme metal, not death metal. Death metal to me was a time, a place and an atmosphere and it takes place in the late 80s to the 90’s. Everything else since then has been a bastardization but too many that are straight up not death metal call themselves death metal. I’m what everyone calls an ‘elitist’ if that means being correct then I’m totally fine with it. Just because something has blast beats and growly vocals, doesn’t make it death metal.” Fair enough!

Travis Ryan has one last message to Australia ahead of their tour in February. “We are not bullshitting – we love playing there and have been trying like crazy to get to Australia. I promise you 0 if you were to type Australia in my email, at least 200 or so would pop up. So trust me when I say, we’re totally dying to come back, it’s going to be insane and we’re really looking forward to seeing you at the shows!”

Catch Cattle Decapitation across Australia and New Zealand in February with special guests Psycroptic . Tickets on sale now via Destroy All Lines. Click here to secure your tickets.

Cattle Decapitation’s new album The Anthropocene Extinction is out now via Nerve Gas. Click here to purchase your copy.

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Fumino Sugiyama, a transgender man, holds his Japanese ID card, which reads “female,” at his home in Tokyo.

“A Really High Hurdle”

Japan’s Abusive Transgender Legal Recognition Process

The procedure in Japan for changing an individual’s legal gender is regressive and harmful. It rests on an outdated and pejorative notion that a transgender identity is a mental health condition, and requires transgender people who want legal recognition to undergo lengthy, expensive, invasive, and irreversible medical procedures. The relevant legislation—known as the “Gender Identity Disorder Special Cases Act”—is contrary to international human rights law and international medical best practices. And while some trans people in Japan desire a diagnosis of “Gender Identity Disorder” (性同一性障害) (GID) and to undergo the medical procedures listed in the law, many do not—and should not be required to do so.

“Transgender” is an inclusive term for anyone whose sex assigned to them at birth does not conform to their lived or perceived gender. It refers to people for whom the designation as “female” or “male” on their birth certificate does not align with the gender that they are most comfortable expressing or would express, if given a choice.

Human Rights Watch interviewed transgender people in Japan who described their struggles to fit into rigid school systems designed around strict gender binaries, to seek and obtain employment, to engage healthcare providers, and to raise families in accordance with their basic rights. The existence of a law in Japan allowing transgender people to change their legal gender signals the government’s willingness to engage with and support transgender people. But Japan’s government needs urgently to address and fundamentally revise the legal recognition process that remains anchored to a diagnostic framework that fails to meet international standards and has been roundly criticized and discredited worldwide. The requirement that a transgender person not have underage children if they wish to secure legal recognition of their gender identity violates transgender people’s right to private and family life. Mandatory surgical interventions amount to coercion. And legal gender recognition is an essential element of other fundamental rights—including the right to privacy, the right to freedom of expression, rights related to employment, education, health, and the ability to move freely.

Those interviewed for this report also described how the GID Special Cases Act itself is a barrier to self-respect and acceptance by society. “It is definitely a system that is wrecking people’s dignity as a human being,” one said. Another transgender man said he believed the law was designed to exclude trans people “in order not to admit the exceptions and so as to keep homogeneity.”

Japan’s national government and courts, including the Supreme Court in 2019, have in recent years repeatedly used pejorative myths and stereotypes in their analysis of transgender peoples’ rights. For example, the government and Supreme Court have expressed concerns related to trans men becoming pregnant, saying they “ may cause confusion in society ” as justification to uphold the law’s sterilization requirement.

Japan’s GID Special Cases Act was drafted in 2003 and came into force in 2004. For that era, it is not unique. Other legal regimes around the world from that period contain similar discriminatory and abusive provisions. Legislatures, domestic courts, and regional human rights courts and bodies have in recent years found that such requirements violate human rights law. Medical expert bodies have, similarly, urged governments to remove medical requirements from legal gender recognition procedures. Most recently, the World Health Organization (WHO) published its new International Classification of Diseases, which removes “gender identity disorders” from the “mental disorders” section much like the American Psychological Association did with “Gender Identity Disorder” in 2012. This progress, as well as international human rights standards, gives Japan a roadmap for reforming its own law.

Achieving the right to legal gender recognition is crucial for transgender people to leave behind a life of marginalization and enjoy a life of social equality and dignity. A simple shift toward allowing people autonomy to determine how their gender is expressed and recorded is gaining momentum. The law should not force people to carry an identity marker that does not reflect who they are. It should also not force transgender people to undergo unwanted medical procedures to be recognized or achieve any of the other associated rights.

The Japanese government should urgently reexamine its law and revise it according to its international human rights obligations and medical best practices to allow transgender people a transparent and quick administrative procedure to change their legal gender.

Recommendations

The government of Japan should work urgently across ministries to realize the recommendation put forward by the United Nations independent expert on sexual orientation and gender identity during his 2018 address to the UN General Assembly. The independent expert called for the elimination of abusive requirements as prerequisites for change of legal sex or gender, including:

Forced, coerced or otherwise involuntary sterilization;
Medical procedures related to transition, including surgeries and hormonal therapies;
Undergoing medical diagnosis, psychological appraisals or other medical or psychosocial procedures or treatment;
Requirements relating to economic status, health, marital, family or parental status; and
Any third-party opinion.

To the Ministry of Justice

Revise Law 111 of 2003, the GID Special Cases Act, to bring it into accordance with international human rights standards and medical best practices so that individuals’ gender marker in the family registry can be changed without having to satisfy any medical conditions. In particular, abolish the current conditions of sex reassignment surgery and irreversible infertility, as well as the requirement that applicants have no underage children.
Ensure that legal recognition of transgender people’s gender identity applies to all aspects of people’s lives.
Recognize that it may be in the best interest of some transgender children and young adults to change their legal gender before the age of majority (currently age 20 and beginning April 1, 2022, age 18), and ensure that transgender children are not excluded from the possibility of applying for legal recognition of their gender identity. Procedures for the consideration of transgender children’s applications should include a mechanism for the transgender child to give their opinion on the need to change their legal gender. The child’s freely expressed opinion needs to be given due weight. In line with Japan’s obligation under the Convention on the Rights of the Child, the relevant procedures should be designed in such a way as to acknowledge that as children grow and acquire capacities, they are entitled to an increasing level of responsibility for the regulation of matters affecting them.
Ensure that the revised legal gender recognition law does not require trans people to be single in order to be legally recognized according to their self-declared gender identity.

To the Ministry of Foreign Affairs

Invite the UN independent expert on sexual orientation and gender identity to visit Japan and meet with transgender people, service providers, and government interlocutors.

To the Ministry of Health, Labor and Welfare

As a matter of urgency, issue a public statement indicating that the ministry will adopt the World Health Organization’s new category of “gender incongruence” and work with the Ministry of Justice to ensure that the GID Special Cases Act is revised in accordance with the WHO’s International Classification of Diseases, version 11.
With the Ministry of Justice, launch a process of revising the GID Special Cases Act to institute a legal gender recognition procedure based on an administrative act of self-declaration of gender identity.
Ensure that transgender people have access to the medical and psychological assistance and support they require, and that such support and assistance is available to transgender individuals within a reasonable time.
In consultation with transgender people, ensure that all medical interventions related to gender transition for transgender people are covered by health insurance schemes.
Ensure that training is available to health service professionals, including psychologists, psychiatrists and general practitioners, as well as social workers, with regard to the specific needs and rights of transgender persons and the requirement to respect their dignity.

Methodology

Human Rights Watch conducted the research for this report between August and December 2015 and additional research between July and November 2018 with individuals from 14 prefectures in Japan. During the time period that elapsed between the phases of research, Human Rights Watch engaged UN Special Procedures regarding Japan’s legal gender recognition procedure, eliciting a response from the government. The law and its implementation has not changed since 2015, when the initial interviews were conducted, so the facts presented remain relevant to analysis of the law today.

Researchers conducted interviews with 48 transgender people, as well as interviews with lawyers, health providers, and academics.

Human Rights Watch researchers obtained informed consent from all interview participants, and provided explanations in Japanese about the objectives of the research and that interviewees’ accounts would be used in a report and related materials. Interviewees were informed that they could stop the interview at any time or decline to answer any questions they did not feel comfortable answering.

No compensation was paid to either survey respondents or those who participated in face-to-face interviews. Human Rights Watch reimbursed public transportation fares for interviewees who traveled to meet researchers in safe, discreet locations. The interviews were conducted in Japanese, or with Japanese-English interpretation. All interviews were conducted privately, with participants interviewed alone.

In this report, pseudonyms are used for all transgender interviewees except those who expressed a strong preference that their real names be used.

Human Rights Watch engaged the United Nations Office of the High Commissioner for Human Rights Special Procedures branch and two UN experts wrote to the Japanese government following our submission. That correspondence, and the government’s response, is analyzed in this report.

Human Rights Watch wrote to Japan’s Ministry of Justice in October 2018 to share our research findings and preliminary recommendations for this report.

I. Gender Identity and Legal Recognition

Everyone has a gender identity. Most people identify as either female or male, in line with what they were assigned on their birth certificates. Some may identify as a gender that is different from the one they were assigned at birth, and some may identify as both, or neither. If someone is labeled “female” at birth but identifies as male, he is a transgender man (or transman). If someone is labeled “male” at birth but identifies as female, she is a transgender woman (or transwoman). In Japan, the identity term “x-gender” is used by some people. It roughly translates to “non-binary” or “genderqueer” in English, signifying a neutral gender identity that is neither male, nor female. The term “cisgender” (i.e., non-transgender) is used for someone who identifies with the same gender, male or female, as the sex they were assigned at birth.

Historically, many medical systems, including those supported by the World Health Organization (WHO), have categorized being transgender as a mental health condition. However, this has been gradually changing, and the WHO has updated its standards—as discussed later in this report.

There is widespread consensus among medical and psychological experts, consistent with the views of transgender communities around the world, that experiencing gender as different from that which was assigned at birth is not a disorder or a disease—but rather a natural variation of human experience. [1]

Transgender people, in Japan and elsewhere, experience mental health problems like everyone else. Research suggests that transgender populations experience higher rates of some mental health problems. Transgender people incur mental health problems from stigma, discrimination, bullying, and harassment that are not inherent in gender non-conformity. These conditions may require diagnoses in order to receive treatment, but they are separate from the experience of gender identity as such.

Transgender people, as per the usage in this report, are not experiencing a form of mental health condition; rather, they experience a deep sense of identification with a gender different from the sex assigned to them at birth. They may or may not take steps to physically alter their bodies, such as undergoing hormone replacement therapy (HRT) or sex reassignment surgery (SRS). They may or may not seek mental health care related to their transition or associated anxieties.

Gender identity is not the same thing as sexual orientation. Like cisgender people, transgender people may identify as heterosexual, homosexual, bisexual, or asexual. Transgender people, like anyone else, can form relationships with people of all other genders.

While there have been some changes in national laws recognizing and protecting transgender people in recent years, [2] many countries, like Japan, still enforce outdated, discriminatory, and coercive policies. As this report details, legal gender recognition procedures such as Japan’s, which mandate medical procedures with irreversible consequences and construe gender identity as a “disorder,” run afoul of international human rights law. Requirements of a minimum age, parental status, and relationship status for undergoing processes to change legal gender are discriminatory.

Changing such laws to respect transgender people’s right to self-declared legal recognition is a human rights imperative. Due to upcoming changes in global diagnostic systems, as set by the WHO, it is also important for Japan to update its legal gender recognition system to come in line with modern medicine. As detailed below, a simple shift toward allowing people autonomy to determine how their gender is expressed and recorded is gaining momentum globally. The law should not force people to carry an identity marker that does not reflect who they are. It should also not force transgender people to undergo unwanted medical procedures to be recognized or achieve associated rights. And it should not construe gender identity as a medical condition in need of diagnosis.

Japan’s Legal Gender Recognition System

Legal gender recognition in Japan is regulated by Law No. 111 of 2003, the “Act on Special Cases in Handling Gender Status for Persons with Gender Identity Disorder”—or the GID Special Cases Act. The law came into effect on July 16, 2004. [3]

The law requires a diagnosis of “Gender Identity Disorder” (GID) before any transgender person can apply to secure legal recognition of their appropriate gender. “GID” is defined in the law as:

A person, despite his/her biological sex being clear, who continually maintains a psychological identity with an alternative gender, who holds the intention to physically and socially conform to an alternative gender. [4]

The process requires the person to receive “concurrent diagnoses on such identification with the opposite gender from two or more physicians equipped with the necessary knowledge and experience to give accurate diagnoses on this matter, based on generally accepted medical knowledge.” [5]

The legal gender recognition decision is made by the Family Court. In addition to providing a certificate attesting to the fact that the individual has been diagnosed with GID, an applicant to the court must meet the following qualifications:

Be 20-years-old or older;
Be presently unmarried;
Not presently have any underage children;
Not have gonads or permanently lack functioning gonads; and
Have a physical form that is “endowed with genitalia that closely resemble the physical form of an alternative gender.” [6]

The GID Special Cases Act is the first legal gender recognition procedure Japan has ever had, and its adoption represented a pivotal moment in the Japanese government’s treatment of sexual and gender minorities. [7] However, the procedure established under the law violates the rights of Japanese people who wish to be legally recognized as having a different gender from the one they were assigned at birth.

In 1980, when the American Psychological Association published the third edition of the Diagnostic and Statistical Manual (DSM-III), psychiatrists in Japan embarked on translating it into Japanese. Karen Nakamura, an anthropologist, explained that there were “debates over what the proper Japanese term might be for the word ‘disorder’ which was used consistently through the DSM. The chief candidates were byô, shô , and shôgai .” [8] Shogai can be translated as “disorder” or disability” – an ambiguity that transgender advocates embraced in 1982 when the DSM-III Japanese version was published. According to Nakamura:

Part of the difficulty is that Japanese medical terminology does not always differentiate between impairment, injury, disorder, disturbance, pathology, and disability when translating these terms as shôgai. In any case, the obfuscation was a happy one for Japanese transsexuals as the DSM-III category of “gender-identity-disorder” became 性同一性障害, seidoitsusei-shogai . [9]

As the concept of GID entered Japanese medical practice and society, it provided an explanatory framework for transgender people to discuss and disclose their identity and access services. The GID diagnosis also became the basis for related legal developments, which culminated in the GID Special Cases Act. And while there was an emancipatory element in the law’s recognition of the experience of a gender identity that does not correspond with the sex one is assigned at birth, the law itself is inconsistent with international human rights law and medical best practices.

The GID Special Cases Act, while serving to acknowledge the existence of a population and allowing for their legal recognition, is a formidable barrier for transgender people in Japan. The requirement of a GID diagnosis is unscientific; the requirement of single marital status and not having minor children is discriminatory; and the requirement of surgeries that sterilize amounts to coerced sterilization. As legal scholar Hiroyuki Taniguchi noted in a 2013 article, “the Act reinforces gender binary not only in social contexts, but also at the physical level by requiring surgical intervention when it is not medically necessary.” [10]

Some transgender people may indeed want to undertake all or some of these actions as part of their transition. However, requiring all transgender people to do so is contrary to international law and a violation of transgender people’s basic rights. The law’s requirements are also regressive with regard to international medical and diagnostic standards. As analyzed later in this report, now that neither of the major international medical diagnostic systems acknowledge “GID” or “transsexualism” as a mental disorder, Japan legally mandating that transgender people obtain such a diagnosis amounts to coercion.

Such a shift may not be insignificant for individuals. As one transgender woman in Tokyo told Human Rights Watch:

I don’t think gender incongruency is a mental disease. However, many have their identity accepted by admitting they have some disorder. If gender incongruence no longer is a disorder, I think there are some who are afraid of losing the way to justify who they are. [11]

Dr. Jun Koh, a psychiatrist in Osaka who works with transgender patients, said:

In Japan, there is a background that social recognition advanced along with the spread of the medical model, in which treatments are carried out based on the diagnosis of a hospital or a clinic. If the medical model is denied, people think it’s about taste and preference – so then there is a chance of not being able to ensure the understanding of transgender being a diversity in gender seen everywhere in the world. [12]

However, while the framework may indeed provide a functional and preferred method for some transgender people to seek care and legal status, the requirements in the current law should not be applied to everyone.

In a 2016 report, the United Nations special rapporteur on torture said that the refusal of transgender people’s legal recognition in their appropriate gender “leads to grave consequences for the enjoyment of their human rights, including obstacles to accessing education, employment, health care and other essential services.” [13] The special rapporteur noted that,

In States that permit the modification of gender markers on identity documents abusive requirements can be imposed, such as forced or otherwise involuntary gender reassignment surgery, sterilization or other coercive medical procedures. [14]

The legal requirements for transgender people in Japan to obtain a GID diagnosis often involves unnecessary, arbitrary, and burdensome tests. The mandatory psychiatric evaluation and the law’s requirements that applicants be unmarried, sterile and lacking any minor children are inherently discriminatory. These conditions—and in particular the maltreatment many transgender people must accept in order to meet them— also amount to cruel and inhuman treatment and to a violation of transgender people’s right to health. The law forces all transgender people who want to secure legal recognition of their appropriate gender to secure diagnosis of a psychological disorder, to refrain from having children at any point during the two decades prior to securing recognition and to be unmarried. It forces many would-be applicants—including those who would not otherwise choose to take these steps— to undergo physically transformative surgical interventions, undergo sterilization, and contemplate the breakup of existing marriages.

Japan’s legal requirements are particularly harmful for transgender children. It sets a mandatory minimum age of 20 for achieving legal gender recognition. Legal recognition can only be given if the individual holds “the intention to physically and socially conform to an alternative gender,” [15] which sets children up to understand surgeries as inevitable and puts intense pressure on them to conform to gender stereotypes about what “male” and “female” bodies and behavior should look like.

These requirements cannot be squared with the principle that the best interests of children be a primary consideration in all administrative and legal decisions that impact them. [16] The GID Special Cases Act negatively impacts children’s rights to physical integrity, privacy, and autonomy. These problems are also reflected in how the government has interpreted the GID Special Cases Act with regard to gender non-conforming children in statements issued by the Ministry of Education [17] , and the guidance issued to psychiatrists on GID patients. [18]

Japan’s current legal gender recognition procedure violates the basic rights of transgender people. It treats the fact of being transgender as a disorder that does not exist—one that transgender people are required to certify that they suffer from as a prerequisite to securing legal recognition. It forecloses legal recognition to transgender people who are married, who have underage children or who have the capacity to reproduce. Not only is this discriminatory, but it forces many transgender people who want to secure legal recognition of their gender identity to contemplate invasive surgical procedures they may not want and, in some cases, requires the breakup of their families.

As one transgender man in Kanagawa Prefecture told Human Rights Watch: “It is definitely a system that is wrecking people’s dignity as a human being.” [19]

Mandatory Psychiatric Evaluation

The GID Special Cases Act requires transgender people in Japan who seek legal recognition of their gender identity to obtain a diagnosis of GID as a prerequisite. Some people in Japan consider their gender identity to be a mental health condition and seek services accordingly. [20] However, such a framework can also stigmatize transgender people. Many of the people whom Human Rights Watch interviewed, including psychiatrists who work with transgender people, discussed this stigma. Our research also found that the process associated with obtaining a medical certificate for GID was itself burdensome and abusive in some cases.

Transgender people Human Rights Watch interviewed reported a variety of experiences in obtaining the GID diagnosis. For example, one was able to obtain the diagnosis certificate on their first visit to a psychiatrist, [21] while in other instances clinic staff and psychiatrists forced applicants to undergo a lengthy and humiliating procedure.

The 4th edition of the Diagnosis and Treatment Guidelines for “Gender Identity Disorder,” published by the Japan Society for Psychiatry and Neurology and last revised in January 2018, recommend three tests for a GID diagnosis:

A gender identity test, which is based on the testimony of the individual;
A biological gender test, which can contain an examination of chromosomes, an examination of hormonal action, an inspection of internal and external genitals, and “other examinations that doctors find necessary”; and
An exclusion of other diagnoses test to “confirm that the denial of gender identity/request for the surgery is not coming from schizophrenia nor other cultural, social, or occupational reasons.” [22]

The only test that contains a reference to the time it can take is test 1, which “may last until enough information will be collected.” [23] Our research found that for some applicants, the process can take an excessive amount of time.

Kiyoshi M., a 24-year-old transgender man in Tokyo, told Human Rights Watch of his year-long effort to obtain the GID diagnosis four years earlier, when he was 20-years-old. On his first visit to a gender clinic in Tokyo, the psychiatrist told him to write his personal history, then return a few weeks later with a series of photos of himself from when he was a toddler through to the present day. “At every session I had to fill out a 100-question questionnaire,” Kiyoshi M. said. According to him, the questions on the survey queried stereotypical understandings of gender-specific behaviors and appearances:

“All of them were open ended questions about gender, such as ‘when I was little, people told me I was____’ or ‘if my parent died, I would react by ____.’”

Kiyoshi M. continued to visit that hospital for six months. “On my first time at the hospital, I told the doctor I wanted the diagnosis as soon as possible,” he said. “But the doctor said to come every two weeks, then even after six months they needed more time and said they couldn’t give [the diagnosis] to me so they told me to keep coming back.” After six months, he gave up and started going to a second hospital in Tokyo, where the psychiatrist at the gender clinic tested him through verbal therapy sessions and interviews for an additional six months before giving him the GID diagnosis. “Clinic staff constantly asked me at every step of the process, ‘Are you sure?’” he said. [24]

Yasuhiro D., a 30-year-old transgender man, traveled to a gender clinic 520 kilometers away from his home for six appointments over the course of two months, where he was subjected to psychiatric tests. “They showed me drawings and I had to talk to the therapist about them many times, it was extremely time consuming and repetitive,” Yasuhiro said. “The drawings were of several people and they asked me which ones looked like my family members.” Once he obtained the GID diagnosis certificate, he went to a clinic closer to Kyoto to request hormone therapy, but they told him he would have to redo all of the tests. “They said it was for a second opinion,” he said. “Then after that second opinion was affirmative, they sent me to an external psychiatrist for a third opinion.” [25]

Hanae T., a 29-year-old transgender woman living in the Ishikawa Prefecture, told Human Rights Watch that it took her nearly a year to get the diagnosis. “I saw the psychiatrist almost the whole year. I kept seeing the psychiatrist until right before the beginning of 2011. It was in December 2010 that I got the diagnosis of GID,” she said. [26]

Coerced Sterilization and Compulsory Surgery

The surgery requirement itself feels wrong. It feels a lot like a surgery to maintain order. Why do we have to put a scalpel through our healthy bodies just for sake of the country’s order? The requirements being incorporated like that into the system—that itself feels as though I am severely insulted or my human rights being neglected. It is humiliating. —Transgender man in Kanagawa Prefecture, September 2018

I don’t want to [have surgery], to be honest. However, I have to just because it is a requirement for marrying in Japan. I feel pressured to be operated on—so terrible. —Transgender man in Tokyo, August 2018

Legal requirements that transgender people undergo surgeries to alter the appearance and function of their bodies amount to coercion. That someone is forced to undergo surgical procedures to obtain legal recognition is itself coercive. And that someone is only afforded access to other rights, such as marriage, after having undergone surgery, is also coercive. Transgender people told Human Rights Watch they found Japan’s surgical requirement to be a substantial burden. Even those who wanted some of the procedures felt rushed onto the operating table by the law requiring them.

“Of course I want to change the gender on my official family register, and have relationships with my significant other,” explained a transgender woman in Tokyo. “But the walls that I have to overcome are just too big. Why do I have to go through so much struggles and challenges just by living?” [27] She said that once she considered the risks associated with the surgeries, she decided not to have them. “Once you start, there’s no going back. The surgery itself also has too many complications, and I would have to keep maintenance for life.”

For some, the surgery was the only gateway toward other rights—for example, the right to marry and enjoy the benefits that come with marriage. Takayuki G., a 24-year-old transgender man in Tokyo, explained: “When we get married, we can receive spousal [tax] deductions.” [28] He said that while he wanted to change his gender in the family register, he had not yet undergone the requisite surgeries because he did not want to. “I feel I am forced to be operated on to get a tax benefit. There are many advantages for marrieds, for example, tax deductions.” [29]

For many, the physical risks and impacts associated with the surgeries were a major barrier. “Another big thing is that I will become infertile if I get the procedure done,” said a 25-year-old transgender man in Tokyo who had not undergone any surgeries. “I am forced to choose between having kids and being lawfully recognized as the gender I associate myself with,” he said. “I am always wondering why this surgery must be part of the requirements. It’s not even like we live our everyday life exposing our genitals to the public.” [30]

A transgender man in Kanagawa Prefecture said he felt that his transition went smoothly because he had his family’s support and he knew what he wanted. However, he told Human Rights Watch, had it not been for the law requiring surgery in order for him to change his legal gender, he would have not undergone the operations. “It was a surgery that I underwent, questioning why I had to put a scalpel to my healthy body,” he said. “I was not able to accept my gender being female on the family register and with that being my top concern, I was inevitably forced to undergo surgery in order to change my gender marker.” [31]

He explained:

If there had not been the requirement of having to undergo surgery, I would have given more thought to it, collecting data and comparing. I would have made a decision when everything had really made sense to me. However, because it was a necessary requirement and because it was an urgent matter due to the fact that I was working, I wanted to change it as soon as possible. [32]

A transgender man in Fukuoka said:

I myself had decided to remove [my uterus] because I don’t want to get the female menstrual cycle. However, my friends around me, their parents are really against them having the surgery. Doing the surgery is a big matter. You could be risking your life. I want there to be an environment where it is possible for people to talk about wanting to change their gender on the family register, without having to do it. From our parents’ perspectives, it must be difficult to understand why we should have a scalpel put to our healthy bodies. [33]

Human Rights Watch interviewed transgender people in Japan who told us that they would not have chosen sterilization if they had had the option to have their gender legally recognized without doing so.

For example, Yasuhiro D., a 30-year-old transgender man in Osaka, said that the recent birth of his brother’s second daughter made him reflect on how his reproductive rights were compromised in his quest to be legally recognized as a man. “Since I had my ovaries when my first niece was born, I even thought about stopping the hormones to make my body able to have children,” Yasuhiro said. He explained:

I thought about this issue of having a child even as I sat waiting in the hospital for the SRS [sex reassignment surgery]. I didn’t have any doubt that I wanted to live as a man, but I also wanted to preserve my ability to have a baby. I had to choose between being legally recognized for who I am and keeping my body the way I wanted it.

He added, “I think a lot of transgender people want to have the surgery; however, having it as a prerequisite for LGR [legal gender recognition] means our reproductive rights are stripped away.” [34]

As Yasuhiro’s account illustrates, compulsory surgery requires transgender individuals who seek legal gender recognition to make an unacceptable choice between exercising their right to recognition as a person before the law and their right to bodily autonomy.

A transgender man who had undergone surgery that sterilized him said:

Back then, I was just really caught up with changing [the gender on] the family register that I could not think about that. But thinking about it now, if it was possible to leave the possibility of having children open, I would have. I really did not have the time to think everything through. [35]

Another transgender woman who has not undergone any surgeries said: “It’s my dream to have my own children. Of course, there are ways to get an adoption, but there’s still the significance of having your own genetic babies.” She explained that she had chosen to carry her documents marked “male,” which had resulted in hardship and discrimination, because she did not want to undergo the legally required surgeries to be recognized as female. “If I had to change my gender, then that would mean giving up all means of reproduction,” she said. “I’m a woman, but I’m not allowed to call myself the mother of my own children. To get the surgery or have children. This is a decision that none of us should be forced to take. It is a despair.” [36]

Others who were contemplating undergoing the law’s required procedures expressed a desire to change their gender, but trepidation about the procedures. For example, Tamaki I., a 27-year-old transgender woman in Osaka, said:

The hurdle is really high. I read that in America you don’t need to have surgery to change your gender; you can just change your gender on the family register. [37] If that becomes true in Japan, I would want to change my gender right now. I can’t understand why the government is asking for such high conditions. I do want to change my legal gender, but surgery has such a high risk, so I don’t know yet. [38]

Noriko R., 22, said: “I want to get my identification card changed. To change it on the family register, we have to get surgery. It’s really a lot of pressure for me.” She worried about the financial burdens: “It costs a lot, and I can’t rely on my parents for help. My transgender friends are waiting for surgery, but I can’t do that, so I feel like I’m becoming isolated, falling behind them.” Noriko said that everyone in her local transgender support group “has some level of pressure about the surgery. Everyone thinks we’ll have to undergo surgery in the future. That’s very tough for us.” [39]

Kiyoshi M., who obtained the GID diagnosis after he spent a year visiting two clinics, and was on hormones when Human Rights Watch interviewed him, but had not undergone surgery, said, “Ideally I would want to just change my legal gender right now. All of these procedures are putting a lot of strain on my body that I don’t want.” [40]

Others highlighted that the surgery requirement does not reflect the lived reality of trans people in Japan. A transgender woman in Tokyo said: “It’s not like getting the surgery will ensure that your life will be better. It’s also not like you show your crotch while you walk around everywhere, so it’s not that terrible.” [41]

Age Restrictions

The GID Special Cases Act bars all transgender people who are younger than 20, Japan’s age of majority (which will be 18 in April 2022), from securing legal recognition of their gender identity. People under 20 can obtain a diagnosis or in some cases a “preliminary diagnosis” of GID. Interviewees told Human Rights Watch they used their GID diagnosis certificates to successfully advocate for access to education according to their gender identity—including through restroom access and school uniforms according to their gender identity.

People who have reached Japan’s age of majority can independently pursue legally required surgical procedures without parental consent. After obtaining a GID diagnosis, a process that varies in length, the subsequent requisite medical procedures can take years and carries considerable costs. As a result, legal gender recognition is sometimes not possible until people have reached their mid-20s even though they have expressed their gender identity and desire to legally transition more than a decade earlier.

But without eliminating the mandatory GID diagnosis and medical interventions, simply reducing the age at which applicants can pursue legal gender recognition will be inadequate. Gender non-conforming children lack access to legal recognition and suffer abuses as a result. In addition, the rigid medical requirements for legal recognition as an adult creates significant anxiety for young people, evident in the accounts of individuals whom Human Rights Watch interviewed.

Japan’s legal age limit is discriminatory and does not allow for the best interests of the child to be considered. This can have a harmful impact on children who are exploring and questioning their gender. A strict age limit can also violate the right to education for those transgender children who desire to attend school according to their gender identity. As discussed below, in its 2015 statement on gender recognition, the World Professional Association for Transgender Health (WPATH) stated that “appropriate legal gender recognition should be available to transgender youth.” [42]

In the context of Japan’s education system, the state’s failure to accord legal recognition of transgender children’s gender identity contributes to their discrimination and degrading treatment. Both the age restriction and the rigid medical criteria are harmful to young people who instead need information, support, and safe spaces to explore and express gender—all elements of inclusive and supportive schools. Furthermore, the current requirement of mandatory medical procedures can cause gender non-conforming children to feel intense pressure to pursue otherwise unwanted medical procedures at a young age.

Japan’s schools feature deeply engrained gender separation based on stereotypes. Nearly all junior high and high school students are required to wear gender-specific uniforms, and school activities are often gender-segregated. [43] For children exploring their gender identity or those who identify as transgender, such an environment can be harsh. Itsuki Dohi, a transgender high school teacher, said:

The Japanese school system is really strict with the gender system. It imprints on students where they belong and don’t belong. In later years, when gender is firmly tracked, transgender kids really start suffering. They either have to conceal and lie or act like themselves and invite bullying and exclusion. [44]

Additionally, the GID Special Cases Act mandate of psychiatric and surgical intervention for transgender people who wish to secure legal recognition of their gender identity can cause anxiety for young people. Dozens of interviewees said that their negative experiences in school when they were forced to dress and present as their birth-assigned sex instead of their gender identity informed their anxieties about the future, including university life and employment. Transgender children as young as 14 looked to the future with trepidation. Some children explained that while they do not necessarily want to undergo the medical procedures required by the GID Special Cases Act, it is currently their only route to social recognition, and—they hope—an end to years of abuse, discrimination and exclusion.

In 2015, the Ministry of Education sent a directive to all school boards titled “Regarding the Careful Response to Students with Gender Identity Disorder.” [45] The Education Ministry directive sends a serious message from the ministry about schools’ responsibility to care for transgender children. However, the directive focusses on diagnoses and medical institutions as the primary source of information about gender and sexuality. For example, the directive states: “The diagnosis and advice from medical institutions is a very crucial opportunity for the school to get a professional knowledge.” This reflects the government’s continued reliance on the harmful, pathological model of understanding transgender people’s gender identity as enshrined in the GID Special Cases Act.

The 2015 Education Ministry directive is official advice, and so its examples of support for schools to follow are nonbinding recommendations. Human Rights Watch interviews with transgender children in Japan revealed that school officials issue varied responses to transgender students’ requests to use facilities according to their gender identity. Enshrining a right to legal recognition of gender based on their self-declared identity alone would substantially improve the situation for transgender children.

Japan should recognize that it may be in the best interest of many transgender children to change their legal gender before they reach age 20. The law should set no absolute minimum age for legal recognition of a transgender person’s gender identity. Instead, the individual circumstances of each child should be assessed by appropriate authorities to determine whether it is in that child’s best interest to change their legal gender. The government should also amend its school-based policies and directives for transgender children to clarify that no child should be required to provide a diagnosis of GID in order to wear uniforms, or access school facilities or activities according to their gender identity.

Relationship Status and Parental Status Discrimination

Japan’s requirement that all applicants for legal gender recognition are single implies mandatory divorce for married transgender people who wish to be recognized. This is because Japan does not recognize same-sex marriages, which a gender transition would create. Such a requirement is discriminatory, and has been condemned by major human rights bodies, including the United Nations Human Rights Council in 2011 and 2014 reports.

The requirement that a transgender person not have underage children (under 20) if they wish to secure legal recognition of their gender identity violates transgender people’s right to private and family life and the right to found a family, and discriminates on those grounds.

The revision of the GID Special Cases Act in 2008 to clarify that transgender people seeking legal gender recognition must not have any children under 20 (previously the law mandated no children whatsoever), demonstrated that the government is willing to consider changes to the law, but it was an insufficient step. [46]

II. Impact of Japan’s Legal Gender Recognition System

The GID Special Cases Act is the first legal gender recognition procedure Japan has ever had, and its adoption represented a pivotal moment in Japan’s public debate on sexual and gender minority issues. [47] And while some activist groups and individuals support the mandatory procedures featured in the law, these have caused significant problems for others.

The diagnostic label of “GID” helped, in some cases, to explain gender identity to families. For example, one transgender man told Human Rights Watch that he pursued a medical certificate for a “GID” diagnosis in an effort to legitimize his transition in the eyes of his parents:

I came out to my parents during New Year’s, but they greatly opposed me. Even if my parents are reluctant to give me approval, I felt as though the certificate to indicate my gender would become beneficial when trying to persuade them. I am still going to the clinic, and the process has prolonged this long, unable to get the certificate. I am very worried that I won’t receive it [soon]. [48]

However, for those who do not undergo the requisite diagnosis and procedures—or those who attempt to, but face barriers such as long delays, failures to obtain a diagnosis—operating in daily life with documents that do not match their identity and appearance causes significant hardship.

“I always try to hide this part of the paperwork whenever I hand it in,” said Aki T., a transgender woman in Tokyo. “Because there is a difference in my body and heart, many people around me get thrown. My heart sinks every time I have to submit any legal documentation, anywhere I go. [49]

Like in Aki’s experience, legal gender recognition is an essential element of other fundamental rights—including the right to privacy, the right to freedom of expression, rights related to employment, education, health, and the ability to move freely.

Access to Education

In 2016, Human Rights Watch published a report that documented bullying and exclusion of lesbian, gay, bisexual, and transgender students in Japanese schools. [50] The report noted significant barriers to accessing education experienced by transgender students, as well as several directives the Ministry of Education had issued in that regard in recent years. While the ministry’s attention to the issues facing transgender students is undoubtedly helping young people thrive, the policies and directives remain grounded in the current law—that is, they refer to trans students as “students with GID.”

In addition to this policy barrier, Japanese school culture, while undergoing important shifts in recent years, [51] remains rigid when it comes to gender norms. Most Japanese schools insist on conformity to strict gender norms as a matter of school policy with regard to uniforms, restroom access, information imparted in classrooms, and other mechanisms of gender norm enforcement.

Student activities are typically gender-segregated, though the degree to which schools enforce gender roles appears to vary. The anxieties this standard system causes transgender and gender-nonconforming students are intense. As one junior high student said, “Gender segregation is everywhere in school—roll call, uniforms, seating arrangement, and hair length are all dictated by gender.” [52] Peter Cave, an anthropologist who studies Japanese education, has documented how even in primary schools, gender differences in the treatment and social conditioning of students are apparent. [53]

Itsuki Dohi, a transgender high school teacher told Human Rights Watch:

The Japanese school system is really strict with the gender system. It imprints on students where they belong and don’t belong. In later years when gender is firmly tracked, transgender kids really start suffering. They either have to conceal and lie or act like themselves and invite bullying and exclusion. [54]

Kaoru M., a 19-year-old transgender woman in Setagaya, said that her school’s “firmly tracked” gender segregation left her isolated: “I expected in high school that there would be more mixing of boys and girls but there was complete social separation.” Kaoru was not allowed to wear a female uniform in high school but wore long hair and had what she described as a “feminized appearance.” She was able to join all-girls extracurricular activities but faced aggressive and scrutinizing questions and teasing from classmates. “I was isolated from both boys and girls,” she said. “There was nowhere to go for me.” [55]

A transgender woman in Tokyo said that the negative experiences she had in school impacted his life:

The disgrace I felt during school had discouraged me so much to the point where I wasn’t able to attend school any longer. In terms of education, I always believed that everything that adults say are always correct. But now, I know that whatever adults [like that] say is almost always incorrect. I had lived my life without hope. [56]

Some students told Human Rights Watch that their schools, to their credit, sought and followed guidance on ensuring transgender students’ rights. A lawyer in Tokyo said that several schools in the city had consulted with him on issues such as uniforms and restroom access when they became aware that they had transgender students, and as a result agreed that students would be able to wear uniforms and have access to lavatories and school activities according to their gender identity. [57] Such approaches by schools appear to be the exception rather than the norm.

School Uniforms

Most of Japan’s junior high and high schools require students to wear uniforms. The attire is gender-specific and the two options, male or female, are dispensed to students according to the sex they were assigned at birth. “The dress codes are usually very strict,” said Mameta Endo, a transgender man who has worked on issues facing LGBT youth in Japan. “The idea behind the uniform is that if you can’t wear it properly, you’re a bad student. It makes you an outcast.” [58]

In some instances that Human Rights Watch documented, students were able to request alterations to their uniforms; in a few cases, students were able to request a full switch of the uniform according to their gender identity. “Schools are really starting to be flexible,” a Tokyo-based lawyer said. [59]

Human Rights Watch, however, identified many agreements to alter uniform requirements that were not the result of consistently applied policies designed to respect students’ right to free expression of their gender identity, but rather due to the compassion of school officials, assiduous advocacy by parents, or in some cases the student’s presentation of their diagnosis with GID. For some transgender students and other children exploring gender identity, the strict uniform policy was an acute source of anxiety, leading to extended school absences and even dropouts. Said the Osaka-based psychiatrist Jun Koh:

Since middle schools and high schools typically require uniforms, this results in the coercion of transgender students, who have questions about their birth-assigned gender, to wear school uniforms that differ from their gender identity. Wearing uniforms result in the complete separation of genders, provoking feelings of gender denial. This leads kids thinking that their feelings are never respected, and it becomes difficult for them to have good self-esteem. It is around this time [when transgender students start entering middle or high schools] that the number of transgender students seeking counselling increases. [60]

For example, Takeshi O. said that his anxieties about the female gender of his school uniform increased over time. “When I first started junior high school I didn’t question the uniform initially,” he said. “I progressively started to question it and by the third year I dreaded every school day because it meant I would have to put the skirt on.” [61]

All of these challenges facing transgender and gender non-conforming youth in Japan’s schools underscore the need to revise the GID Special Cases Act to accommodate and support transgender people regardless of their age.

University Education

In July 2018, news broke that some women’s universities in Japan were revising their admissions policies to admit transgender women. According to an article in the Nikkei Asian Review ,

A panel of experts under the Science Council of Japan's law committee pointed out last year that denying transgender students’ admission to girls' schools and women's universities constitutes "an encroachment on their rights to learn." The panel includes representatives from women's colleges. [62]

Human Rights Watch reached out to Ochanomizu University in Tokyo regarding their stated intent to admit trans women. We inquired about their planned criteria for determining gender identity among applicants. The public relations manager of the university, an all-women’s institution in Tokyo, replied explaining:

Regarding the admission of trans women, we have adopted the method of receiving requests prior to the entrance examination application period, and confirming the eligibility of requirement. Then, after explaining the measures that will be taken upon entering the student life and receiving consent, they will be eligible to take the entrance exam. For those who have made the request, they will be asked to submit their self-declaration of their own gender disparity and gender identity, and if they possess one, a document confirming their gender identity (certificate from a medical doctor, documents written by high school teachers or parents, etc.). Then, the eligibility of application will be considered. [63]

That the medical certificate appears to not be a requirement for admissions to Ochanomizu University is a promising step towards a rights-based self-declaration procedure for trans people to secure official recognition.

Implications for Health Care, Employment, and Travel

Absent identity documents that match their gender presentation, transgender people who seek health care may be subjected to invasive questioning and humiliation. For example, a 30-year-old trans man in Osaka told Human Rights Watch that before he had changed his legal gender, he avoided getting medical care:

Before, I hated going to the hospital because my insurance card was marked as female. So my health was at risk because of that fear. Once I had such bad pain in my stomach and my partner forced me to go to the hospital. I hesitated for several days, but she forced me to go. Otherwise I would have died. [64]

Transgender people in Japan who do not—or cannot—undergo the requisite procedures to change their legal gender risk harmful exposure when seeking employment or in the workplace. The legal regime can even impact how young people think about their future. For example, an 18-year-old trans man university student in Okinawa said:

I’m happy like this [without surgery]. But I think I might have to do more operations and fully transition before applying for a job because that’s what people expect of me – the full GID procedure. That’s the pressure on me right now. I’m happy, but the future feels horrible already. [65]

Others told Human Rights Watch that revealing their gender identity led to pejorative and discriminatory treatment. “Job hunting is a really big deal. I went to my college career center and came out to them,” a 22-year-old x-gender person in Tokyo said. “They told me ‘You’re the minority, you can’t expect all of these things to work out for you.’ Because of that I decided to take time off from college and see a psychiatrist.” [66]

Simply moving from one place to another can be a dangerous and humiliating experience for people whose documents do not match their expression. The stakes are high, particularly for international travel, and range from fraud accusations and exposure to intense scrutiny and humiliation. United Nations human rights experts have condemned such targeting of transgender people in security processes. [67]

“Being legally recognized is good because I have my documents and I no longer have to explain to anybody about myself,” a trans man in Osaka said. “I had always dreamed of living smoothly – like nothing was wrong and that’s what I have now. For work, travel, all administrative interactions.” [68]

III. Japan’s Legal System’s Treatment of Transgender People

In a 2004 legal volume written to help interpret the GID Special Cases Act, Nouno Chieko, the leader of the Members of Parliament group when the law was adopted in 2003 and who served as Japan’s justice minister from 2004-2005, wrote:

Having “to not have gonads or to permanently lack functioning gonads” as a requirement is due to the fact that it was decided that after the legal sex reassignment was admitted, it was not appropriate to remain having reproductive organs of the original sex, or for the gonads to be releasing hormones of the original sex. Thereby, if after legal sex reassignment is carried out, there happens to be a case in which an offspring is born from the remaining reproductive organs, it could cause various [kinds of] confusion and problems. In addition, the possibility of unfavorable effects is not deniable if hormones are released from the gonads of the original sex. [69]

This analysis is based on hypothetical fears of negative social outcomes if transgender people were to retain their reproductive capacity. It does not have a basis in science and runs contrary to human rights standards and medical best practice guidelines. Unfortunately, while this explanation of the law was written over a decade ago, the same ill-informed and discriminatory ideas about trans people remain at the root of the Japanese government’s analysis today.

In 2016, Human Rights Watch wrote to the United Nations special rapporteur on the right of everyone to the enjoyment of the highest attainable standard of physical and mental health and the UN special rapporteur on torture and other cruel, inhuman or degrading treatment or punishment regarding Japan’s legal gender recognition law. [70] The Special Rapporteurs exchanged letters with Japan’s Ministry of Health in Japan. [71]

The Special Rapporteurs critiqued several aspects of Japan’s legal gender recognition law as being in violation of international human rights law. They found that the sterilization requirement in Japan’s law especially abusive and discriminatory:

[S]ubjecting transgender persons to forced or otherwise involuntary gender reassignment surgery, sterilization or other coercive medical procedures is abusive, is rooted in discrimination, and violates the rights to physical integrity and self-determination of individuals and amount to ill-treatment or torture, and recommends that forced and coerced sterilization be outlawed in all circumstances, that special measures be adopted to protect individuals belonging to marginalized groups from such forced or coercive sterilization, that other abusive requirements for legal recognition of gender identity be abolished, and that transparent and accessible legal gender recognition procedures be adopted. [72]

While the government responded that the GID Special Cases Act is “exercised appropriately, taking into consideration international humanitarian [sic] laws and universal standards,” [73] the government’s defense of the GID Special Cases Act indicates several fundamental misunderstandings of gender identity as it is understood in international medical and legal standards.

Regarding the requirement of a diagnosis of “GID,” the government said: “The requirement also aims to prevent claims by persons claiming gender identity disorder for a change in gender status without having obtained a diagnosis.”

The government emphasized that,

In order to ensure that recognition of Gender Identity Disorder be made objectively and certainly, concurrent diagnoses from two or more physicians are required, and those diagnoses should be made “based on generally accepted medical knowledge.”

Generally accepted medical knowledge with regard to gender identity has changed substantially since the GID Special Cases Act was passed. As analyzed in the following section, it is not generally accepted medical knowledge that a diagnosis should be required for legal recognition; in fact, global transgender health expert bodies have called for the complete separation of medical and legal processes. [74] Furthermore, the diagnosis of “transsexualism” or “Gender Identity Disorder” is no longer recognized in either of the two major international diagnostic manuals, the Diagnostic and Statistical Manual (DSM) and the International Classifications of Diseases (ICD).

Regarding the criticism of the sterilization requirement as a human rights violation, the government responded:

When a person, after having had a change in legal gender status recognized, procreates using the reproductive function of the former gender, it may give rise to confusion and various problems.

This argument suggests that transgender men who wanted to provide eggs or get pregnant, or transgender women who wanted to provide sperm to conceive a child, should have their rights to do so curtailed in order to prevent “confusion.” While it is reasonable to expect that some people may be confused by a pregnant man, for example, such hypothetical social fears do not justify the coerced sterilization of a person.

Regarding the requirement that the applicant have no minor children, the government wrote:

The requirement that the person “currently has no child who is a minor” is stipulated, taking into consideration the arguments that this system could give rise to confusion within the family, including between parent and child, or influence the child’s welfare.

Chieko’s legal analysis mirrored this claim, arguing that a “child may get psychological confusion or anxiety, or it may affect the parent-child relationship.” [75] This assertion is based on pejorative and unfounded assumptions that transgender people cannot be good parents. In fact, research has shown that transgender people can be—and are—good parents, and their relationships with their children are good. [76]

Unfortunately, courts in Japan have followed similarly flawed logic in their judgments regarding transgender people’s rights.

Court Cases

Human Rights Watch is only aware of one case in which an individual directly challenged the sterilization requirement of Japan’s legal gender recognition law in court (a case in 2005 challenged the no-child requirement only). In February 2018, a High Court in Okayama ruled on the case of Takakito Usui, a 43-year-old transgender man who had brought a case to the court challenging the GID Special Cases Act on the grounds that the requirement of surgery violated Japan’s constitution.

In the case, the Hiroshima High Court ruled that the GID Special Cases Act existed to avoid confusion, contending:

If there is an incidence where a child is born based on the reproductive capabilities of the previous gender after the parent undergoes a gender change under the procedure of the special case act, there are issues where the current legal system is unable to deal with, which may cause confusion in the legal order of personal status. [77]

The court further ruled that “it is not appropriate for an individual to maintain the reproductive capabilities of their previous gender.” [78] The court’s decision in this case runs counter to international human rights law, and serves to uphold a harmful, discriminatory, and outdated paradigm.

In January 2019, the Supreme Court issued its judgment in Usui’s case, upholding the GID Special Cases act as constitutional at this time, stating that there is a “need to avoid abrupt changes in a society where the distinction of men and women have long been based on biological gender.”

However, the four-judge bench noted that, “It cannot be denied that [this law] impinges on freedom from invasion of bodily [integrity].”

Two of the justices in a concurring opinion wrote of the urgency of Usui’s case, and the need to reform Japan’s law: “The suffering that [transgender people] face in terms of gender is also of concern to society that is supposed to embrace diversity in gender identity.” They noted that “because gender is treated as one of the attributes of an individual in social life and in personal relationships, it can be said that gender is inseparable from the existence as a person of an individual.” They concluded that for transgender people, being “able to receive rulings of changes in recognition of gender status…is an important, perhaps even urgent, legal benefit.” [79]

Other Japanese court decisions in recent years demonstrate the complexities of interpreting a law that recognizes a population of people—the transgender population—as people who have rights, but also construes them as suffering from an illness, “GID,” that does not in fact exist. Nevertheless, within this framework, transgender individuals have challenged instances of discrimination in courts and in many instances, won. The list of cases below is illustrative, not comprehensive, and some of the cases are still pending, so publicly available information about them is limited.

IV. International Law, Best Practices for Gender Recognition

International human rights standards are increasingly understood to require the separation of legal and medical processes of gender reassignment for transgender people. During the 2017-2018 cycle of Japan’s Universal Periodic Review at the United Nations Human Rights Council in Geneva, New Zealand issued a recommendation that Japan “[t]ake steps to address discrimination based on sexual orientation and gender identity, including revising the Gender Identity Disorder Law.” [87] The government of Japan responded “supporting” the recommendation, indicating its commitment to implement the recommendation before its next review, which will take place in 2022. [88]

In his report to the UN General Assembly in 2018, the independent expert on sexual orientation and gender identity, Victor Madrigal-Borloz, stated:

[L]ack of legal recognition negates the identity of the concerned persons to such an extent that it provokes what can be described as a fundamental rupture of State obligations. As expressed by one scholar, when States deny legal access to trans identities, what they are actually doing is messaging a sense of what is a proper citizen. [89]

Transgender people whom Human Rights Watch interviewed in Japan felt similarly. Asked what he thought of the justification for the surgical requirement in Japan’s legal gender recognition law, Takayuki G., a trans man in Tokyo, said:

Japan is cold to even slightly exceptional people, so this provision should be it. They use the word ‘not proper’ in order not to admit the exceptions and so as to keep homogeneity…The law is created in order not to give rise to exceptions and that’s why it’s ‘not proper’ that people who have male genitals marry men. [90]

The International Covenant on Civil and Political Rights (ICCPR) provides for equal civil and political rights for all (article 3), the right to recognition for everyone before the law (article 16), the right to one’s privacy and family (article 17), and the right of people of marriageable age to marry and to start a family (article 23(2)).

Governments are obligated under the ICCPR to ensure equality before the law and the equal protection of the law of all persons without discrimination on any ground, including sex (article 26). The UN Human Rights Committee, the international expert body that monitors state compliance with the ICCPR, has specifically recommended that government should guarantee the rights of transgender persons including the right to legal recognition of their gender, and that states should repeal abusive and disproportionate requirements for legal recognition of gender identity. [91]

Several countries have adopted best practices that reflect this. Sweden, the Netherlands, Ireland, Colombia, Malta, and Denmark in recent years changed their legal recognition procedures to remove invasive medical requirements; Denmark and Malta, along with Argentina, do not require a medical diagnosis for legal gender recognition. [92] Argentina and Malta are widely considered to set best standards in legal gender recognition procedures. [93] In some countries, legislatures have adopted these standards in laws and policies; in other countries, courts have required the application of these principles.

In 2013, the UN special rapporteur on torture stated that, “In many countries transgender persons are required to undergo often unwanted sterilization surgeries as a prerequisite to enjoy legal recognition of their preferred gender.” [94] The special rapporteur noted a trend of finding such compulsory sterilization a violation of human rights, including non-discrimination rights and physical integrity, and called upon governments “to outlaw forced or coerced sterilization in all circumstances and provide special protection to individuals belonging to marginalized groups.” [95]

A 2012 Office of the High Commissioner for Human Rights (OHCHR) report, prepared in response to a 2011 Human Rights Council resolution calling for an end to violence and discrimination on the basis of sexual orientation and gender identity, noted that “[r]egulations in countries that recognize changes in gender often require, implicitly or explicitly, that applicants undergo sterilization surgery as a condition of recognition. Some States also require that those seeking legal recognition of a change in gender be unmarried, implying mandatory divorce in cases where the individual is married.” [96]

In a 2014 joint statement, the WHO, OHCHR, UN Program on HIV/AIDS (UNAIDS), the UN Development Programme, UNICEF, and UNFPA said: “States parties’ obligation to respect the right to health requires that they abstain from imposing discriminatory practices. This includes an obligation to respect the rights of persons with disabilities and transgender and intersex persons, who also have the right to retain their fertility.” [97] The agencies called on governments to “[p]rovide legal guarantees for full, free and informed decision-making and the elimination of forced, coercive and otherwise involuntary sterilization, and review, amend and develop laws, regulations and policies in this regard.” [98] In 2017, the Board of Directors of the Japanese Society of Gender Identity Disorder, the first and the largest Japanese organization founded in 1999 for professionals working on GID, adopted a statement in support of this report, noting that “it can be assumed that if the requirements stated in Article 3 Section 1 of the Special Cases Act, especially the “surgery requirement,” did not exist, the situation would have been vastly different.” [99]

In a 2015 report, mandated by a 2014 Human Rights Council resolution on sexual orientation and gender identity, OHCHR recommended that states begin immediately “[i]ssuing legal identity documents, upon request, that reflect preferred gender, eliminating abusive preconditions, such as sterilization, forced treatment and divorce.” [100]

The 2015 Blueprint for the Provision of Comprehensive Care for Trans People in Asia and the Pacific , co-published by WHO, UNDP, USAID, PEPFAR, the Asia-Pacific Transgender Network, and the Health Policy Project, recommended that governments “[t]ake all necessary legislative, administrative, and other measures to fully recognize each person’s self-defined gender identity, with no medical requirements or discrimination on any grounds.” [101]

Similarly, principle 3 of the Yogyakarta Principles on the Application of International Human Rights Law in relation to Sexual Orientation and Gender Identity states that:

Everyone has the right to recognition everywhere as a person before the law. Persons of diverse sexual orientations and gender identities shall enjoy legal capacity in all aspects of life. Each person’s self-defined sexual orientation and gender identity is integral to their personality and is one of the most basic aspects of self-determination, dignity, and freedom. No one shall be forced to undergo medical procedures, including sex reassignment surgery, sterilization or hormonal therapy, as a requirement for legal recognition of their gender identity. No status, such as marriage or parenthood, may be invoked as such to prevent the legal recognition of a person’s gender identity. No one shall be subjected to pressure to conceal, suppress, or deny their sexual orientation or gender identity. [102]

Regional bodies have followed the logic of these principles.

In June 2013, the Parliamentary Assembly of the Council of Europe, a regional body comprised of 47 member states, passed Resolution 1945, calling for an end to coercive sterilization and castration. Transgender people are listed as one of the groups in the Council of Europe countries disproportionally affected by coercive sterilization. [103] Similarly, in January 2018 the Inter-American Court of Human Rights issued an advisory opinion which maintained that states are obligated under the American Convention to establish efficient, inexpensive, and straightforward legal gender recognition procedures based solely on the “the free and autonomous decision of each person” and that forcing transgender people to argue for a change in gender markers before a judge would constitute an “excessive limit” on their rights. [104]

International health expert bodies have in recent years strengthened their positions against medical models for legal gender recognition. The WPATH, an international multidisciplinary professional association aimed at promoting evidence-based care, education, research, advocacy, public policy, and respect in transgender health and comprised of over 700 members worldwide, called for removal of any sterilization requirements as part of legal gender recognition in a 2010 statement. [105] WPATH stated:

No person should have to undergo surgery or accept sterilization as a condition of identity recognition. If a sex marker is required on an identity document, that marker could recognize the person’s lived gender, regardless of reproductive capacity. The WPATH Board of Directors urges governments and other authoritative bodies to move to eliminate requirements for identity recognition that require surgical procedures. [106]

In 2015 the WPATH updated the statement, reiterating its condemnation of forced sterilization, and expanding its critique of arduous and medicalized procedures for legal gender recognition, saying: “No particular medical, surgical, or mental health treatment or diagnosis is an adequate marker for anyone’s gender identity, so these should not be requirements for legal gender change”; and, “Marital status and parental status should not affect legal recognition of gender change, and appropriate legal gender recognition should be available to transgender youth.” [107]

And in 2017, WPATH updated their position statement again, reiterating that:

WPATH further recognizes the right of all people to identity documents consistent with their gender identity, including those documents which confer legal gender status…. Transgender people, regardless of how they identify or appear, should enjoy the gender recognition all persons expect and deserve. Medical and other barriers to gender recognition for transgender individuals may harm physical and mental health. WPATH opposes all medical requirements that act as barriers to those wishing to change legal sex or gender markers on documents. [108]

Implementation around the World

The Science Council of Japan, an independent organization under the ministry of cabinet, representing Japanese scientists in social sciences, life sciences, natural sciences, and engineering, according to a report published in September 2017, recommends removing “GID” terminology, and suggests there have been conversations underway inside the Japan Society of Psychology and Medicine to adopt “gender incongruence” terminology instead. [109] The council also recommends removing the surgical, divorce, and no-children requirement from the law, saying:

Upon the establishment of the Special Cases Act, the law makers were aware that gender has a direct connection to personal identity, and therefore has issues to the 13th Article of the Constitution of Japan, is a persons’ right to pursue happiness and dignity. Taking into consideration the trends of the world, including the joint statement by the World Health Organization (2014), it is now the time to reconsider the requirements in order to secure the unalienable rights to pursue happiness and human dignity. [110]

To reach its conclusions, the council cited legal and medical changes that have taken place in recent years around the world, many of which are explored in this report.

As the special rapporteur on torture noted in his 2013 report, national courts in several countries have begun to reflect these standards in their decisions as well. The special rapporteur’s report refers to the following domestic cases:

In 2009, the Austrian Administrative High Court ruled that mandatory gender reassignment, as a condition for legal recognition of gender identity, was unlawful. [111]
In 2011, the Constitutional Court in Germany found that the requirement of gender reassignment surgery violated the rights to physical integrity and self-determination. [112]
In 2012, the Swedish Administrative Court of Appeals ruled that forced sterilization could not be seen as voluntary. [113]
In September 2014 the Norwegian Equality Body ruled that the Ministry of Health had provided no justification for the sterilization requirement in its gender recognition law, and thus the sterilization requirement was deemed to contravene the Anti-Discrimination Act. [114]

Courts in some Asian countries have demonstrated a similar commitment to medical non-interference in legal gender recognition processes, including in the following cases:

In a 2007 judgment, the Nepal Supreme Court’s definition of a third gender category situated it as a minority encompassing a broad range of identities for transgender and gender non-conforming people. [115] A 2014 study found that respondents wrote in 16 different terms for their gender identities. [116] The court made clear that the sole criterion for being legally recognized as third gender on documents and in government registers was an individual’s “self-feeling.” [117] The judgment cited the right to recognition before the law, guaranteed under article 16 of the ICCPR, as well as the Yogyakarta Principles.
In 2013, India’s Supreme Court stated that undertaking medical procedures should not be a requirement for legal recognition of gender identity. The court said: “Few persons undertake surgical and other procedures to alter their bodies and physical appearance to acquire gender characteristics of the sex which conform to their perception of gender, leading to legal and social complications since official record of their gender at birth is found to be at variance with the assumed gender identity.” It continued: “Gender identity, therefore, refers to an individual’s self-identification as a man, woman, transgender or other identified category.” The court made it clear that mandatory sterilization was not acceptable: “no one shall be forced to undergo medical procedures, including SRS, sterilization or hormonal therapy, as a requirement for legal recognition of their gender identity.” [118]
In 2015, the Delhi High Court reinforced that, “Everyone has a fundamental right to be recognized in their gender” and that “gender identity and sexual orientation are fundamental to the right of self-determination, dignity and freedom.” [119]

Rights of Trans Children

The right to recognition as a person before the law is articulated in the Universal Declaration of Human Rights and guaranteed in the ICCPR and the Convention on the Rights of the Child (CRC). [120] The right to preserve one’s identity is guaranteed by article 8 of the CRC, which specifies three aspects of identity—nationality, name, and family relations—but that list is not exhaustive. Together with the right to protection from arbitrary interference in privacy, such as ICCPR article 17, the right to preserve one’s identity extends to the way one’s identity is reflected on state-issued documents—including for children.

As the CRC makes clear, “In all actions concerning children, whether undertaken by public or private social welfare institutions, courts of law, administrative authorities or legislative bodies, the best interests of the child shall be a primary consideration.” [121] This includes decisions about legal recognition of the gender identity of transgender children.

Article 12 of the CRC provides that in determining the child’s best interest, the child itself should be heard and taken into account:

Governments should assure to the child who is capable of forming their own views the right to express those views freely in all matters affecting the child, the views of the child being given due weight in accordance with the age and maturity of the child.
For this purpose, the child shall in particular be provided the opportunity to be heard in any judicial and administrative proceedings affecting the child, either directly, or through a representative or an appropriate body, in a manner consistent with the procedural rules of national law. [122]

Diagnostic Shifts

Psychiatrists in Japan use both the International Classification of Diseases (ICD), which is published by the UN WHO, and the Diagnostic and Statistical Manual (, which is published by the American Psychiatric Association (APA). Both the DSM and the ICD have removed the diagnoses for “GID” and “transsexualism” from “mental disorders” sections altogether.

In 2012 the APA board’s changes to the latest DSM removed the term “Gender Identity Disorder.” APA instead added the term “Gender Dysphoria” with the specific definition that it refers to emotional distress over “a marked incongruence between one’s experienced/expressed gender and assigned gender.” The APA specifically clarified: “It is important to note that gender nonconformity is not in itself a mental disorder. The critical element of gender dysphoria is the presence of clinically significant distress associated with the condition.” [123]

The WHO published a revised version of the ICD in June 2018. [124] The new WHO guidelines reframe “gender identity disorders” as “gender incongruence,” and move the diagnostic codes from the chapter on mental disorders to one on sexual health—an important gain for transgender adolescents and adults, who may soon be able to seek medical care without being viewed as “mentally disordered.” The World Health Assembly, the governing body of the WHO, which features representatives from 194 member states, will likely approve ICD-11 in 2019. Governments will then have until 2022 to change their diagnostic coding systems. According to the WHO, “evidence is now clear that [gender identity] is not a mental disorder, and indeed classifying it in this can cause enormous stigma for people who are transgender.” [125] As one member of the ICD-11 working group that undertook the revisions process explained,

WHO, a United Nations agency, has a human rights mission, and there is substantial evidence that the stigma associated with the intersection of transgender status and mental disorders contributes to precarious legal status, human rights violations, and barriers to appropriate health care for this population. [126]

The SOGI Independent Expert noted that this change signaled clearly that “there is no reason to assign a diagnosis to trans people who do not seek gender-affirming medical treatment or some sort of bodily change.” [127]

Japan’s legal recognition procedure is out of step with that recommended model on multiple levels, including because it requires transgender people to undergo medical procedures to secure legal recognition of their gender identity. This has contradictory effects. To some extent the fact that gender-affirming medical procedures are available in Japan reflects advances in medical practices and the medical community’s embrace of care for transgender people. But it also reinforces a pathological model that contributes to stigmatization of transgender people.

Acknowledgments

Research for this report was conducted by Kyle Knight, researcher in the lesbian, gay, bisexual, and transgender rights program; Kanae Doi, Japan director; and Michael Garcia Bochenek, senior children’s rights counsel at Human Rights Watch.

We wish to thank Fumino Sugiyama, Itsuki Dohi, Yuko Higashi from Osaka Prefecture University for their expertise and support in conducting the research. Riyo Yoshioka, Japan Senior program officer, Teppei Kasai, Japan program officer, Emily Okabe, Kanako Nannichi, Kota Ono, Yuto Takeda, Ayako Ogo, and Kan Kikumoto, Tokyo office interns, offered outreach and desk research support. Naho Toivonen, an intern in Human Rights Watch’s London office in 2016, provided significant background research and analysis on some of the legal cases referenced in this report.

Graeme Reid, director of the LGBT rights program, Kanae Doi, and Michael Bochenek edited the report. James Ross, legal and policy director, and Danielle Haas, senior program editor, provided legal and programmatic review. Tetz Hakoda and Yuki Akimoto were the Japanese translators, and Hiroyuki Taniguchi was the specialist reviewer of the Japanese translation of this report. Production assistance was provided by MJ Movahedi, LGBT rights program coordinator, and Fitzroy Hepkins, administrative manager.

We wish to thank the trans people who shared their stories with us.

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Cattle Decapitation: Forced Gender Reassignment

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Cattle Decapitation's Forced Gender Reassignment is an incredibly graphic and brutal 5 minute short film which focuses on 3 people who get abducted during a anti-gay rally, only to awake in ... Read all Cattle Decapitation's Forced Gender Reassignment is an incredibly graphic and brutal 5 minute short film which focuses on 3 people who get abducted during a anti-gay rally, only to awake in a filthy basement and get mutilated and tortured by a masked freak. Cattle Decapitation's Forced Gender Reassignment is an incredibly graphic and brutal 5 minute short film which focuses on 3 people who get abducted during a anti-gay rally, only to awake in a filthy basement and get mutilated and tortured by a masked freak.

Mitch Massie
Josh Elmore
Derek Engemann
Klint Lucas
2 User reviews
Dave McGraw
Christine Murphy
J. Scott Myers

Travis Ryan
Brett Siler
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The abuser : Say it, say it.

The abuser : Say fuck God, say fuck God.

The abuser : Say it you filthy cunt.

The abuser : Say it.

The abuser : Fuck God, fuck God, fuck God.

The abuser : Scream it, scream it you piece of shit.

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Oct 7, 2017
October 12, 2012 (United States)
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David Reimer and John Money Gender Reassignment Controversy: The John/Joan Case

In the mid-1960s, psychologist John Money encouraged the gender reassignment of David Reimer, who was born a biological male but suffered irreparable damage to his penis as an infant. Born in 1965 as Bruce Reimer, his penis was irreparably damaged during infancy due to a failed circumcision. After encouragement from Money, Reimer’s parents decided to raise Reimer as a girl. Reimer underwent surgery as an infant to construct rudimentary female genitals, and was given female hormones during puberty. During childhood, Reimer was never told he was biologically male and regularly visited Money, who tracked the progress of his gender reassignment. Reimer unknowingly acted as an experimental subject in Money’s controversial investigation, which he called the John/Joan case. The case provided results that were used to justify thousands of sex reassignment surgeries for cases of children with reproductive abnormalities. Despite his upbringing, Reimer rejected the female identity as a young teenager and began living as a male. He suffered severe depression throughout his life, which culminated in his suicide at thirty-eight years old. Reimer, and his public statements about the trauma of his transition, brought attention to gender identity and called into question the sex reassignment of infants and children.

Bruce Peter Reimer was born on 22 August 1965 in Winnipeg, Ontario, to Janet and Ron Reimer. At six months of age, both Reimer and his identical twin, Brian, were diagnosed with phimosis, a condition in which the foreskin of the penis cannot retract, inhibiting regular urination. On 27 April 1966, Reimer underwent circumcision, a common procedure in which a physician surgically removes the foreskin of the penis. Usually, physicians performing circumcisions use a scalpel or other sharp instrument to remove foreskin. However, Reimer’s physician used the unconventional technique of cauterization, or burning to cause tissue death. Reimer’s circumcision failed. Reimer’s brother did not undergo circumcision and his phimosis healed naturally. While the true extent of Reimer’s penile damage was unclear, the overwhelming majority of biographers and journalists maintained that it was either totally severed or otherwise damaged beyond the possibility of function.

In 1967, Reimer’s parents sought the help of John Money, a psychologist and sexologist who worked at the Johns Hopkins Hospital in Baltimore, Maryland. In the mid twentieth century, Money helped establish the views on the psychology of gender identities and roles. In his academic work, Money argued in favor of the increasingly mainstream idea that gender was a societal construct, malleable from an early age. He stated that being raised as a female was in Reimer’s interest, and recommended sexual reassignment surgery. At the time, infants born with abnormal or intersex genitalia commonly received such interventions.

Following their consultation with Money, Reimer’s parents decided to raise Reimer as a girl. Physicians at the Johns Hopkins Hospital removed Reimer’s testes and damaged penis, and constructed a vestigial vulvae and a vaginal canal in their place. The physicians also opened a small hole in Reimer’s lower abdomen for urination. Following his gender reassignment surgery, Reimer was given the first name Brenda, and his parents raised him as a girl. He received estrogen during adolescence to promote the development of breasts. Throughout his childhood, Reimer was not informed about his male biology.

Throughout his childhood, Reimer received annual checkups from Money. His twin brother was also part of Money’s research on sexual development and gender in children. As identical twins growing up in the same family, the Reimer brothers were what Money considered ideal case subjects for a psychology study on gender. Reimer was the first documented case of sex reassignment of a child born developmentally normal, while Reimer’s brother was a control subject who shared Reimer’s genetic makeup, intrauterine space, and household.

During the twin’s psychiatric visits with Money, and as part of his research, Reimer and his twin brother were directed to inspect one another’s genitals and engage in behavior resembling sexual intercourse. Reimer claimed that much of Money’s treatment involved the forced reenactment of sexual positions and motions with his brother. In some exercises, the brothers rehearsed missionary positions with thrusting motions, which Money justified as the rehearsal of healthy childhood sexual exploration. In his Rolling Stone interview, Reimer recalled that at least once, Money photographed those exercises. Money also made the brothers inspect one another’s pubic areas. Reimer stated that Money observed those exercises both alone and with as many as six colleagues. Reimer recounted anger and verbal abuse from Money if he or his brother resisted orders, in contrast to the calm and scientific demeanor Money presented to their parents. Reimer and his brother underwent Money’s treatments at preschool and grade school age. Money described Reimer’s transition as successful, and claimed that Reimer’s girlish behavior stood in stark contrast to his brother’s boyishness. Money reported on Reimer’s case as the John/Joan case, leaving out Reimer’s real name. For over a decade, Reimer and his brother unknowingly provided data that, according to biographers and the Intersex Society of North America, was used to reinforce Money’s theories on gender fluidity and provided justification for thousands of sex reassignment surgeries for children with abnormal genitals.

Contrary to Money’s notes, Reimer reports that as a child he experienced severe gender dysphoria, a condition in which someone experiences distress as a result of their assigned gender. Reimer reported that he did not identify as a girl and resented Money’s visits for treatment. At the age of thirteen, Reimer threatened to commit suicide if his parents took him to Money on the next annual visit. Bullied by peers in school for his masculine traits, Reimer claimed that despite receiving female hormones, wearing dresses, and having his interests directed toward typically female norms, he always felt that he was a boy. In 1980, at the age of fifteen, Reimer’s father told him the truth about his birth and the subsequent procedures. Following that revelation, Reimer assumed a male identity, taking the first name David. By age twenty-one, Reimer had received testosterone therapy and surgeries to remove his breasts and reconstruct a penis. He married Jane Fontaine, a single mother of three, on 22 September 1990.

In adulthood, Reimer reported that he suffered psychological trauma due to Money’s experiments, which Money had used to justify sexual reassignment surgery for children with intersex or damaged genitals since the 1970s. In the mid-1990s, Reimer met Milton Diamond, a psychologist at the University of Hawaii, in Honolulu, Hawaii, and academic rival of Money. Reimer participated in a follow-up study conducted by Diamond, in which Diamond cataloged the failures of Reimer’s transition.

In 1997, Reimer began speaking publicly about his experiences, beginning with his participation in Diamond’s study. Reimer’s first interview appeared in the December 1997 issue of Rolling Stone magazine. In interviews, and a later book about his experience, Reimer described his interactions with Money as torturous and abusive. Accordingly, Reimer claimed he developed a lifelong distrust of hospitals and medical professionals.

With those reports, Reimer caused a multifaceted controversy over Money’s methods, honesty in data reporting, and the general ethics of sex reassignment surgeries on infants and children. Reimer’s description of his childhood conflicted with the scientific consensus about sex reassignment at the time. According to NOVA, Money led scientists to believe that the John/Joan case demonstrated an unreservedly successful sex transition. Reimer’s parents later blamed Money’s methods and alleged surreptitiousness for the psychological illnesses of their sons, although the notes of a former graduate student in Money’s lab indicated that Reimer’s parents dishonestly represented the transition’s success to Money and his coworkers. Reimer was further alleged by supporters of Money to have incorrectly recalled the details of his treatment. On Reimer’s case, Money publicly dismissed his criticism as antifeminist and anti-trans bias, but, according to his colleagues, was personally ashamed of the failure.

In his early twenties, Reimer attempted to commit suicide twice. According to Reimer, his adult family life was strained by marital problems and employment difficulty. Reimer’s brother, who suffered from depression and schizophrenia, died from an antidepressant drug overdose in July of 2002. On 2 May 2004, Reimer’s wife told him that she wanted a divorce. Two days later, at the age of thirty-eight, Reimer committed suicide by firearm.

Reimer, Money, and the case became subjects of numerous books and documentaries following the exposé. Reimer also became somewhat iconic in popular culture, being directly referenced or alluded to in the television shows Chicago Hope , Law & Order , and Mental . The BBC series Horizon covered his story in two episodes, “The Boy Who Was Turned into a Girl” (2000) and “Dr. Money and the Boy with No Penis” (2004). Canadian rock group The Weakerthans wrote “Hymn of the Medical Oddity” about Reimer, and the New York-based Ensemble Studio Theatre production Boy was based on Reimer’s life.

Carey, Benedict. “John William Money, 84, Sexual Identity Researcher, Dies.” New York Times , 11 July 2016.
Colapinto, John. "The True Story of John/Joan." Rolling Stone 11 (1997): 54–73.
Colapinto, John. As Nature Made Him: The Boy who was Raised as a Girl . New York: HarperCollins Publishers, 2000.
Colapinto, John. "Gender Gap—What were the Real Reasons behind David Reimer’s Suicide." Slate (2004).
Dr. Money and the Boy with No Penis , documentary, written by Sanjida O’Connell (BBC, 2004), Film.
The Boy Who Was Turned Into a Girl , documentary, directed by Andrew Cohen (BBC, 2000.), Film.
“Who was David Reimer (also, sadly, known as John/Joan)?” Intersex Society of North America . http://www.isna.org/faq/reimer (Accessed October 31, 2017).

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The Gender Reassignment Controversy

When people opt for surgery, are they satisfied with the outcome.

Posted March 16, 2018 | Reviewed by Ekua Hagan

In an age of increasing gender fluidity, it is surprising that so many find it difficult to accept the gender of their birth and take the drastic step of changing it through surgery. What are their motives? Are they satisfied with the outcome?

Gender may be the most important dimension of human variation, whether that is either desirable, or inevitable. In every society, male and female children are raised differently and acquire different expectations, and aspirations, for their work lives, emotional experiences, and leisure pursuits.

These differences may be shaped by how children are raised but gender reassignment, even early in life, is difficult, and problematic. Reassignment in adulthood is even more difficult.

Such efforts are of interest not just for medical reasons but also for the light they shed on gender differences.

The first effort at reassignment, by John Money, involved David Reimer whose penis was accidentally damaged at eight months due to a botched circumcision.

The Money Perspective

Money believed that while children are mostly born with unambiguous genitalia, their gender identity is neutral. He felt that which gender a child identifies with is determined primarily by how parents treat it and that parental views are shaped by the appearance of the genitals.

Accordingly, Money advised the parents to have the child surgically altered to resemble a female and raise it as “Brenda.” For many years, Money claimed that the reassignment had been a complete success. Such was his influence as a well-known Johns Hopkins gender researcher that his views came to be widely accepted by scholars and the general public.

Unfortunately for Brenda, the outcome was far from happy. When he was 14, Reimer began the process of reassignment to being a male. As an adult, he married a woman but depression and drug abuse ensued, culminating in suicide at the age of 38 (1).

Money's ideas about gender identity were forcefully challenged by Paul McHugh (2), a leading psychiatrist at the same institution as Money. The brunt of this challenge came from an analysis of gender reassignment cases in terms of both motivation and outcomes.

Adult Reassignment Surgery Motivation

Why do people (predominantly men) seek surgical reassignment (as a woman)? In a controversial take, McHugh argued that there are two main motives.

In one category fall homosexual men who are morally uncomfortable about their orientation and see reassignment as a way of solving the problem. If they are actually women, sexual interactions with men get redefined as heterosexual.

McHugh argued that many of the others seeking reassignment are cross-dressers. These are heterosexual men who derive sexual pleasure from wearing women's clothing. According to McHugh, surgery is the logical extreme of identifying with a female identity through cross-dressing.

If his thesis is correct, McHugh denies that reassignment surgery is ever either medically necessary or ethically defensible. He feels that the surgeon is merely cooperating with delusional thinking. It is analogous to providing liposuction treatment for an anorexic who is extremely slender but believes themselves to be overweight.

To bolster his case, McHugh looked at the clinical outcomes for gender reassignment surgeries.

Adult Reassignment Results

Anecdotally, the first hurdle for reassignment is how the result is perceived by others. This problem is familiar to anyone who looked at Dustin Hoffman's depiction of a woman ( Tootsie ). Diligent as the actor was in his preparation, his character looked masculine.

For male-to-female transsexuals, the toughest audience to convince is women. As McHugh reported, one of his female colleagues said: “Gals know gals, and that's a guy.”

According to McHugh, although transsexuals did not regret their surgery, there were little or no psychological benefits:

“They had much the same problems with relationships, work, and emotions, as before. The hope that they would emerge now from their emotional difficulties to flourish psychologically had not been fulfilled (2)”.

Thanks to McHugh's influence, gender reassignment surgeries were halted at Johns Hopkins. The surgeries were resumed, however, and are now carried out in many hospitals here and around the world.

What changed? One likely influence was the rise of the gay rights movement that now includes transgender people under its umbrella and has made many political strides in work and family.

McHugh's views are associated with the religious right-wing that has lost ground in this area.

Transgender surgery is now covered by medical insurance reflecting more positive views of the psychological benefits.

Aspirational Surgery

Why do people who are born as males want to be women? Why do females want to be men? There seems to be no easy biological explanation for the transgender phenomenon (2).

Transgender people commonly report a lifelong sense that they feel different from their biological category and express satisfaction after surgery (now called gender affirmation) that permits them to be who they really are.

The motivation for surgical change is thus aspirational rather than medical, as is true of most cosmetic surgery also. Following surgery, patients report lower gender dysphoria and improved sexual relationships (3).

All surgeries have potential costs, however. According to a Swedish study of 324 patients (3, 41 percent of whom were born female) surgery was associated with “considerably higher risks for mortality, suicidal behavior, and psychiatric morbidity than the general population.”

1 Blumberg, M. S. (2005). Basic instinct: The genesis of behavior. New York: Thunder's Mouth Press.

2 McHugh, P. R. (1995). Witches, multiple personalities, and other psychiatric artifacts. Nature Medicine, 1, 110-114.

3 Dhejne, S., Lichtenstein, P., Boman, M., et al. (2011). Long-term follow-up of transsexual persons undergoing sex reassignment surgery: Cohort study of Sweden . Plos One.

Nigel Barber, Ph.D., is an evolutionary psychologist as well as the author of Why Parents Matter and The Science of Romance , among other books.

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[Exclusive] Cattle Decapitation Release What Might Just Be The Most NSFW Music Video Ever

Okay, I’ve seen some bizarre, twisted, and downright fucked up music videos in my time. But there wasn’t really anything that could’ve prepared me for Cattle Decapitation ‘s “Forced Gender Reassignment”. Let me put it like this: when a video is too intense for YouTube, it gets on Vimeo. That site will let almost anything slide. Nope. Vimeo flat out rejected it, wanting nothing to do with it. But we at Bloody-Disgusting are never ones to shy away from bringing you the most vile visual material out there. So we gladly accepted the opportunity to not only premiere this video for you all, but also to be the only site on the internet with the balls to host it .

So, if you’ve got the guts (and the stomach), you can watch this INCREDIBLY NSFW video below. But don’t say we didn’t warn you.

Also, do us a favor and record your reaction of the video and post the video link in the comments below!

“Forced Gender Reassignment” comes from Cattle Decapitation’s latest album Monolith Of Inhumanity ( iTunes ). The band also has a ton of tour dates coming up. You can see the schedule for all the shows below.

WARNING : The video you are about to watch is incredibly gory, violent, and features strong sexual violence including rape and sexual assault. Bloody-Disgusting does not endorse or condone any of the actions seen in this video. It is to be viewed as entertainment only .

Travis Ryan

“ For the Forced Gender Reassignment video I wanted something mean and cruel and flat out disturbing. It seems nowadays you have to be over the top in your presentation to get anyone to think about anything anymore. The song is about taking certain religious sects and showing them what its like to be in another person’s shoes – someone whose life is simply different than theirs – but forcibly so, of course, or else it just wouldn’t be Cattle Decapitation. A band heavily steeped in irony, pessimism and fucking pain. There was no second choice – Mitch Massie was the only person for the job. He helped put our vision directly on the screen and we couldn’t be more happier and at the same time repulsed by the aftermath. ”

Mitch Massie

“ Travis threw down the gauntlet and asked for something based around the lyrics to this insane song. Of course I had to accept the challenge. Have free reign to create something that could piss people off, make family members hate me even more, potentially ruin my future with more delicate bands, and make a complete audio/visual ‘fuck you’ in the most unapologetic way? Hell yes, count me in. This time the lyrics had to be visualized realistically as opposed to metaphorically so an absolute-bat-shit-insane cast was needed. Truly, nothing is more life affirming or fun than to shoot a project full of violence, rape, and mutilation with a group who has no fear of anything. So much of this video is real that I’ve never laughed so much in my life while being seconds away from a trip to the emergency room every day. Caleb Schneider is a personal hero of mine for creating the ‘appliance’ and having enough faith in me to do it justice. Getting a box of dicks in the mail is a very special yet humbling moment in one’s life. It was no surprise that Travis had a difficult time finding a place to show this disgusting and very bloody project but it is amazing, ironic, and fitting that Bloody Disgusting decided to support it. I’m thankful all of our work can be heard and seen in the right place. I hope this isn’t the last time I get to do something this outrageous and awful. I would love to do a Taylor Swift video based on Story of the Eye. ”

CATTLE DECAPITATION 10/29 Denver, CO The Marquis Theatre 10/30 Kansas City, MO The Beaumont Club* w/ Gwar 10/31 St. Louis, MO Fubar

w/ Six Feet Under , Wretched 11/02 Richmond, VA Kingdom 11/03 Frederick, MD Cafe 611 11/04 Clifton, NJ Dingbatz 11/05 Boston, MA Middle East 11/06 New York, NY The Studio at Webster Hall 11/07 Buffalo, NY Club Infinity 11/08 Reading, PA Reverb 11/09 Amityville, NY Revolution 11/10 Dayton, OH McGuffy’s 11/12 St Paul, MN Station-4 11/13 Joliet, IL Mojoe’s 11/14 Lansing, MI Mac’s Bar 11/15 Peoria, IL The Brass Rail 11/16 Valparaiso, IN Roadie’s Music Venue 11/17 Louisville, KY Phoenix Hill Tavern 11/18 Atlanta, GA Masquerade End tour

11/20 Trenton, NJ Backstage at Champs 11/21 Brooklyn, NY Saint Vitus Bar 11/23 Roanoke, VA Coffin House

w/ Dying Fetus , Cerebral Bore 11/25 West Columbia, SC New Brookland Tavern 11/27 Tampa, FL Brass Mug 11/29 Longview, TX The Levee 11/30 Houston, TX Warehouse Live 12/01 Corpus Christi, TX Zero’s 12/02 San Antonio, TX Korova 12/04 Dallas, TX Tree’s 12/05 El Paso, TX House Of Rock 12/06 Tempe, AZ Rocky Point 12/07 Hollywood, CA The Whisky 12/08 Fullerton, CA Slidebar (Matinee) 12/09 San Francisco, CA DNA Lounge 12/10 Stockton, CA Plea For Peace 12/11 Richland, WA Ray’s Golden Lion 12/12 Seattle, WA Studio 7 12/13 Boise, ID The Venue

Cattle Decapitation on-line: Official Website Facebook YouTube Twitter

Mitch Massie: YouTube

Got any thoughts/questions/concerns for Jonathan Barkan? Shoot him a message on Twitter or on Bloody-Disgusting !

Managing editor/music guy/social media fella of Bloody-Disgusting

Mondo Brings ‘An American Werewolf in London’ and ‘Halloween II’ Exclusives to Monsterpalooza This Weekend

Mondo is going big for Monsterpalooza ‘s fifteenth anniversary, commencing this weekend in Pasadena, California. Expect a slew of horrifying new drops, exclusive posters, and figures. We’ve got an exclusive sneak peek at limited An American Werewolf in London and Halloween II soft vinyl figures and posters that will launch at the convention.

The nightmare demon werewolves that torment David Kessler ( David Naughton ) in his sleep and Michael Myers get articulated in soft vinyl figure form, along with two new exclusive posters that put the werewolves front and center.

Look for Mondo to go all out this weekend, with many more collectibles and surprises in store. They teased on socials , ” Keep an eye on our socials for some extra frights that weekend, too. It’s gonna be a scream..”

The classic 1981 horror comedy An American Werewolf in London follows David Kessler and Jack Goodman, two college friends from New York City, on an increasingly terrifying backpacking trip through England. When they stumble upon a pub called The Slaughtered Lamb during a full moon night, the hostile locals have one piece of advice: Stay on the road and keep clear of the moors…

The 1981 sequel Halloween II picked up immediately after the events of the 1978 slasher classic, following Laurie Strode (Jamie Lee Curtis) to Haddonfield hospital where she faces off against Michael Myers once more.

Details and images below on Mondo’s An American Werewolf in London collectibles appearing at Monsterpalooza:

AWIL Nightmare Demon Soft Vinyl Werewolf (Regular) – $95 ONLINE

Haunt your dreams (and your shelf) with the Nightmare Demon Werewolf Soft Vinyl Figure! Inspired by 20th century Japanese sofubi, our AN AMERICAN WEREWOLF IN LONDON Nightmare Demon soft vinyl line features premium, swivel-articulated figures complete with swappable portraits and weapons.

AWIL Nightmare Demon Soft Vinyl Mutant (Regular) – $95 ONLINE

Haunt your dreams (and your shelf) with the Nightmare Demon Mutant Soft Vinyl Figure! Inspired by 20th century Japanese sofubi, our AN AMERICAN WEREWOLF IN LONDON Nightmare Demon soft vinyl line features premium, swivel-articulated figures complete with swappable portraits and weapons.

Halloween II – Michael Myers Soft Vinyl Figure $95 ONLINE

Terrorize Haddonfield with the HALLOWEEN II – Michael Myers Soft Vinyl Figure! Inspired by 20th century Japanese sofubi, this premium, swivel-articulated figures comes complete with swappable portraits and weapons from the 1981 film.

An American Werewolf in London Poster (by Florian Bertmer) – $80 Online

Mondo presents a new limited edition, screenprinted poster by illustrator Florian Bertmer for the 1981 horror/comedy film AN AMERICAN WEREWOLF IN LONDON.

An American Werewolf in London Poster (by Jérôme “Trëz” Oudot) – $80 FLOOR

Mondo presents a new limited edition, screen-printed poster by artist Jérôme “Trëz” Oudot for the 1981 horror/comedy film AN AMERICAN WEREWOLF IN LONDON.

Art by Florian Bertmer

Jérôme "Trëz" Oudot An American Werewolf in London

Art by Jérôme “Trëz” Oudot

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Toddler At Children's Hospital waits for Surgery

Kate Sosin, The 19th Kate Sosin, The 19th

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Most state bans on gender-affirming care for trans youth still allow controversial intersex surgery

This article was originally published by The 19th on March 23, 2023.

When Georgia lawmakers advanced a bill earlier this month that would ban gender-affirming care for youth, many argued that kids were too young to be making big health care decisions.

“We’re asking that children be 18 years old before they make this decision that will alter their lives forever,” Republican Sen. Carden Summers said, according to an ABC news article.

Summers’ argument is not uncommon. Opponents of trans rights have argued that kids are ill-equipped to decide on gender-related medical interventions. Those arguments largely confuse what gender-affirming health care for youth is.

READ MORE: The fight to end intersex surgeries at a top hospital took a deep toll on activists

Still, Georgia’s bill does not outlaw irreversible gender-related surgeries on all kids. In fact, if the bill becomes law, Georgia will become one of several states to pass laws backing pediatric sex-related surgeries that have been condemned by the United Nations for more than a decade: those for people born intersex.

More than two-thirds of the bills introduced this year that would ban gender-affirming care for transgender youth have specific intersex exemptions. The controversial exemptions allow doctors to assign minors who are born with secondary sex characteristics as “male” or “female” through surgeries, hormones or other interventions.

“So you’re saying that trans kids are too young to consent, but intersex kids aren’t?” asked Bria Brown-King, director of engagement for the intersex rights group InterAct. “How does that make sense?”

Sean Saifa Wall, an intersex scholar and activist, believes that medical interventions for trans kids and intersex kids have become conflated.

“We as a society do not understand the experiences of trans people and trans children,” said Wall. “A lot of trans young people don’t get surgeries until they’re 18. That’s what often happens to intersex young people, but because we don’t understand, we don’t understand neither trans nor intersex experiences, these bills float on by.”

Intersex conditions are common, according to scientists. A 2000 study by Brown University professor Dr. Anne Fausto-Sterling found that 1.7 percent of the population is born intersex. That’s about the same percentage of people born with red hair.

While doctors have operated on intersex minors to assign them “male” or “female” sexes for decades, human rights organizations have long condemned the surgeries on kids as cosmetic, unnecessary and inhumane. That’s because many procedures are done on kids in infancy, without their knowledge or consent.

Intersex adults often only discover they are intersex by accident, they report . Some have grown up being told by doctors or parents that they had painful surgeries because they had cancer . In reality, they learned, the surgeries were done to assign them a binary sex.

In 2013, the United Nations issued a report that called for an end to “genital-normalizing surgery, involuntary sterilization, unethical experimentation, medical display, ‘reparative therapies.’”

“A lot of these things are presented as medical problems that require fixing that are not actually medical problems,” Maddie Moran, director of communications for InterACT, said.

The movement to outlaw intersex surgeries in the United States has made big strides in the last three years. Two prominent hospitals — Chicago’s Lurie Children’s Hospital and Boston Children’s Hospital — have stopped offering pediatric intersex procedures. The Biden administration has also been meeting with intersex advocates to talk about how to end the surgeries nationwide. In the meantime, California, often a leader on LGBTQ+ rights, has introduced a bill to ban pediatric intersex surgeries. The bill has yet to gain enough support to pass.

But as the intersex rights movement becomes more mainstream, it has also become a target. According to InterAct and the National Center for Transgender Equality, more than two-thirds of the bills that target transgender medical care introduced this year (82 out of 120) have carve-outs for pediatric intersex procedures. Those carve-outs have consequences, advocates say: Some of the first explicit anti-intersex language is being written into law.

“The bills are really authorizing in the law, the practice of performing these unnecessary surgeries,” Moran said. “They are surgeries that are already happening . . . but they are now authorizing that practice in the law, which is the opposite of the direction that we want to be going.”

Wall thinks the bills are not about protecting children at all and said they are really about reinforcing rigid gender ideals and heterosexuality.

“I see the attack on trans people, and I see the mandates to continue doing surgeries on intersex infants and children as a way of crushing bodily autonomy as a way of upholding ‘male’ and ‘female’ as sacred,” he said. “This harm has been really endemic and it’s been long-standing. The scary part about it, though, is when there’s a codifying it into law.”

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The Moving Image

A Perfect Daughter: Gender Reassignment by Gillian Laub

N ikki was born Niko. A biological boy at birth, she began at the age of 10 the complicated transition to becoming girl. With the utmost support of her family and friends, two years later, she is living happily as the person she always knew herself to be — singing, acting and dancing, often draped in pink.

Earlier this summer, PEOPLE magazine commissioned photographer Gillian Laub to spend several days with Nikki’s family in California, documenting her life after the transition through video and photographic stills. Her portrait shows what it was like for Nikki coming out with her gender identity, finding solace in puberty-blocking medication and looking to the gender reassignment surgery on the horizon for her teenage years.

“It’s always an honor when someone is open and wants to share their life in such an intimate way under the gaze of a camera,” Laub tells TIME, “so the minute the editor told me about Nikki, I said of course I would love to do it.”

To gain their trust and to make them feel comfortable, Laub spent the first day just talking with the family without her cameras.

“Nikki told me she spent the first ten years of her life feeling like she was in the wrong body, almost betrayed by it,” she says. “After the transition, she finally felt happy, safe and proud in her body. I wanted to convey the new feeling of freedom and liberation.”

What stood out to Laub most and what she aimed to capture in the video above was how immensely loving Nikki’s family was. With the knowledge that 50% of transgender youth will attempt to commit suicide by the age of 20, they strove to provide all the support they could for their child to lead the life she wanted.

“Although this story ultimately is a very happy ending,” Laub says, “the family went through years of heartache and stress. They lived with a secret that they all struggled with for very long. The reason they were sharing their story publicly is because they wished they had known sooner that this was actually something many families deal with; they wouldn’t have had so many years of worry and confusion.”

Gillian Laub is a photographer based in New York and a frequent contributor to TIME. See more of her work here .

Eugene Reznik is a Brooklyn-based photographer and writer. Follow him on Twitter @eugene_reznik .

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Forced Gender Reassignment Tab

Cattle decapitation.

A poor bill of health

Systemic barriers and prejudice are increasingly depriving trans people in russia of healthcare.

Photo: EPA-EFE/RICCARDO ANTIMIANI

LGBTQ+ rights groups Coming Out and Sphere published their annual report on the lives of queer people in Russia on 17 May, coinciding with the International Day against Homophobia, Transphobia and Biphobia. While documenting the increasing levels of violence and oppression LGBTQ+ people face over two years into Russia’s war in Ukraine, the survey also highlighted the growing issue of medical discrimination.

The investigation found that one in five people in Russia identifying as LGBTQ+ has faced discrimination from doctors, varying from denial of treatment to outright aggression. Transgender individuals emerged as the most vulnerable, being refused treatment even more frequently in the past year than in the year before, something experts attribute to a Russian law introduced last year that banned gender reassignment surgery.

‘They flat out refused me’

Trans people in Russia face significant barriers when seeking gender-affirming care. Administrative complications and outright refusal from medical professionals meant 19-year-old Oleg was unable to legally change the gender marker on his passport before the Russian parliament passed a law banning such changes in July.

To apply for an amended passport, Oleg required documents from three different specialists. This included the signature of a sexologist, a specialist present in a limited number of hospitals. To avoid any issues getting the required signatures, Oleg confirmed that the doctors were available multiple times prior to his appointments in a hospital in the western Siberian city of Omsk.

Yet on the day of his scheduled appointments, Oleg was told at reception that the sexologist he had confirmed his appointment with in advance was not at the hospital. Later, during his scheduled appointment with a psychiatrist, Oleg was told the hospital had no sexologist as their specialist had resigned three months earlier.

“The psychiatrist replied that she would not issue a certificate because she did not know how to do so. They flat out refused me.”

“During the appointment she spoke condescendingly, asking me why I needed ‘all this’,” Oleg told Novaya Europe. “She said she didn’t know how this type of appointment worked and left to speak with her colleagues. When she came back she told me that the hospital didn’t have a sexologist so the hospital couldn’t provide me with the documents I needed.”

The psychiatrist did not provide Oleg with an answer when asked why the sexologist was still listed as staff on the hospital website.

Activists protest the Russian Supreme Court deeming the “international LGBT movement” extremist outside the Russian Embassy in Belgrade, Serbia, 13 December 2023. Photo: Andrej Cukic / EPA-EFE

Then Oleg asked the doctor to give him a certificate with an official diagnosis of “transsexualism”, a document needed to receive hormone therapy or undergo gender reassignment surgery prior to its ban in July.

Oleg arranged for emergency appointments with specialists in Moscow to get the required documents before the Russian parliament’s ban on passport gender revision came into force. Despite submitting these on time, Oleg’s application for new documents was turned down, a decision his lawyers described as illegal.

Several years ago Yekaterina legally changed her gender but remained eligible for military conscription as she is a doctor. Last year she decided to get herself declared “temporarily unfit for combat” to avoid being conscripted.

“The military conscription office thought long and hard about what I needed to qualify. They suggested I obtain a gynaecological certificate confirming the absence of female reproductive organs,” Yekaterina said, explaining that it could be considered a hormonal problem.

“I went to the gynaecologist, but they refused to issue me with a certificate. The gynaecologist was a man and he refused to examine me. I spoke to management but they also turned me down.”

High-cost care

There are two main problems for trans people in Russia when seeking medical care: the first is the refusal of professionals to provide gender-affirming care and the second is a general rejection of trans identities.

This has only become worse since the ban on gender reassignment surgery came into effect. Doctors in Russia are now less likely to provide care to trans people for fear of committing an offence within the broad scope of the bill’s vague wording. This means some individuals are denied gender-affirming therapy despite having legally changed their gender.

“The practice is completely contradictory,” a lawyer representing Coming Out told Novaya Europe.

“Some doctors will simply make a diagnosis and then treat patients. Others will only provide care after receiving approval from the Health Ministry. It’s a matter of legal interpretation. The difficulty is in doctors being forced to shoulder responsibility, which makes them afraid of breaking the law and losing their medical licence or job.”

Some trans people have told Coming Out that they were refused appointments in clinics using their regular medical insurance, despite being legally entitled to an examination with a specialist if they have officially changed their gender.

While such transphobic refusals are technically illegal, punishing such discrimination is difficult as the gender reassignment law is so vague, Coming Out’s lawyer told Novaya Europe.

Attaining justice is further complicated by Russia’s ban on “the international LGBT movement” introduced in November. Anyone filing a legal complaint exposes their transgender identity and thus becomes vulnerable to accusations of “extremism”, a charge that comes with a maximum 10-year prison sentence. Often the only option for transgender people in Russia is to go to a private clinic, where they can choose their own doctors.

“Being a trans person in Russia is very expensive,” the lawyer stressed. “If you are trans you cannot always get state medical care, due either to transphobia, or to the systemic barriers that individuals simply cannot overcome.”

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Toward an Intersectional Approach to Sexual and Reproductive Health Policies in Brazil

By guest contributor Mariana Rodrigues

Brazil faces critical challenges in sexual and reproductive health, including high rates of unplanned pregnancies, maternal morbidity and mortality , increasing prevalence of unsafe abortions , and significantly low usage and adherence to pre-exposure prophylaxis (PrEP). Despite recent progress in public health initiatives, including expanded family planning services and efforts to address menstrual poverty, significant gaps persist in addressing the complex structural factors that impact access to sexual and reproductive healthcare.

Individuals at the intersection of multiple minoritized identities face disproportionate health impacts and barriers to healthcare access. For instance, Sexual and Gender Minority (SGM) individuals are significantly affected by the lack of societal awareness surrounding their unique needs,perpetuating their invisibility and hindering access to essential services. Challenges in ensuring access to Brazil’s Unified Health System (SUS) for transgender individuals include discrimination in healthcare services, the pathologizing of transgender identities, and the requirement of gender-reassignment surgery as a criterion for access.These barriers, coupled with the absence of specific primary care policies and insufficient resources for promoting sexual and reproductive health, further compound the challenges faced by SGM individuals.

Similarly, Black women encounter barriers at every stage of their healthcare journey, from the initial search for services to the actual care provision. Structural racism and limited accessibility contribute to limited opportunities for reproductive planning, higher risks of unintended pregnancies, and difficulties in accessing contraceptives. Although a discussion of Brazil’s abortion laws and conservative agenda is beyond the scope of this commentary, it is crucial to highlight that abortion legislations in Brazil significantly exacerbate existing health disparities. Due to such barriers , women are forced to look for unsafe alternatives for abortion and only seek health care when complications arise. These barriers disproportionately affect young, Black, and low-income women , highlighting systemic issues of racism and discrimination within Brazil’s sexual and reproductive healthcare. Overall, the challenges faced by marginalized communities in Brazil’s sexual and reproductive healthcare system reveal deep-rooted systemic issues that call for an intersectional approach to research and policy.

Coined by Kimberlé Crenshaw , intersectionality is a theoretical framework that acknowledges how multiple identities (i.e., race/ethnicity, gender identity, sexual orientation) intersect and interact with systems of oppression leading to unique experiences and barriers. Adopting an intersectional approach involves recognizing how these intersecting identities and their interactions with power structures, influence individuals’ access to resources, opportunities, healthcare, and sexual and reproductive health outcomes, especially for those with multiple minoritized identities.

While progress has been made in analyzing health disparities in Brazil with a holistic approach, intersectionality remains underutilized in research and policy. Brazilian researchers have historically focused on social class when examining healthcare issues, neglecting invisible processes affecting those at the intersection of multiple minoritized identities, such as socioeconomic backgrounds, race, sexual orientation, and gender identity. Indeed, there is a critical need for research that prioritizes Young (18-29) SGM of color, who face disproportionate challenges yet lack comprehensive studies and policies addressing their unique needs and challenges in sexual and reproductive health.

Notably, a few studies have examined the sexual and reproductive health needs of SGM individuals in Brazil. For instance, the “PrEParadas” study found that Black transgender women with lower education levels had lower PrEP adherence, emphasizing the importance of considering intersecting identities and the impact of multiple axes of oppression. Additionally, a qualitative study highlighted significant challenges faced by transgender women in Brazil related to PrEP use and adherence, including stigma, discrimination in the public health system (SUS), and lack of trans-specific healthcare services. These findings underscore the need for research that holistically addresses these barriers and informs the development of tailored interventions to improve the sexual and reproductive health of individuals at the intersection of multiple minoritized identities.

Overall, adopting an intersectional approach allows for an inclusive analysis and consideration of the unique needs of marginalized communities, leading to more targeted interventions and solutions. It involves developing culturally competent services, community-based outreach programs, comprehensive sexual education, and strategies to reduce systemic barriers that not only center the discussions around marginalized groups but make them key actors in societal change. In addition, a critical need exists for disaggregated, nationally-wide data collection that allows for a more comprehensive understanding of the unique needs of individuals with multiple marginalized identities. By addressing the barriers and challenges in sexual and reproductive health with an intersectionality approach, we can effectively prioritize tailored solutions rather than a “one-size-fits-all” approach.

About the author:

Mariana Rodrigues is a licensed Clinical Psychologist in Brazil and holds a Master’s degree in Clinical Psychology from Columbia University. Currently, she is a Ph.D. student in Social & Behavioral Sciences at the New York University School of Global Public Health, working under the supervision of Dr. Stephanie Cook. Mariana’s primary research interests include exploring the structural and environmental factors that impact the health and well-being of individuals at the intersection of multiple minoritized identities, as well as the protective (e.g., perceived social support, community connectedness) that might mitigate such impacts. Her ultimate goal is to inform the development and optimization of culturally-sensitive interventions to reduce health and healthcare disparities.

Disclaimer: Views expressed by contributors are solely those of individual contributors, and not necessarily those of PLOS.

By guest contributors Meg Davis, Sharifah Sekalala, Franco Serra, Belinda Rawson, Molly Pugh-Jones, and Leo Anthony Celi This week, Transform Health Coalition…

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SC governor again signs bill banning gender-affirming care, but this time it's ceremonial

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South Carolina Gov. Henry McMaster held a ceremonial signing in Spartanburg Wednesday for two bills focused on children.

House Bill 4624, called the Help not Harm Bill, bans certain medical care for transgender youth, while House Bill 3424, or the Child Online Safety Act, restricts access to pornographic websites for minors by requiring the websites to have age verification.

Legislators said the bills were to ensure children were protected in South Carolina.

“We have to see that we take care of our children, but we can’t be there all the time. So somebody has to look out for them,” McMaster said during the ceremony held at First Baptist North Church.

The Child Online Safety Act was inspired by a similar law passed in Louisiana, according to the lead sponsor, Rep. Travis Moore (R-Spartanburg.) The new bill ensures websites containing pornography have age verifications on its websites, and if they fail to do so, will result in “liability for nominal damages, actual damages, court costs, and reasonable attorney fees as ordered by the court.”

“I agree it’s a parent’s job and primary responsibility to raise and protect their children,” Moore said. “But when you deal with issues like this, evils that are so pervasive, the parents are outnumbered and that’s where it’s appropriate for the state to step in and produce policy to help parents protect their children.”

The bills became effective immediately after McMaster signed them on May 21. House Bill 4624 bill prohibits any form of puberty-blocking or hormone therapy. It also makes it a felony to perform gender reassignment surgery on those under 18.

“We don’t know how many surgeries have taken place in South Carolina related to this issue, but one is too many,” said state Rep. David Hiott (R-Pickens), lead sponsor of the bill.

More: South Carolina Gov. McMaster signs bill outlawing transgender care for trans youth

Under the new bill, minors can still be prescribed puberty blockers or hormone therapy to treat certain conditions such as precocious puberty or endometriosis. The law also bans the South Carolina Medicaid program from providing coverage for gender reassignment surgery or hormone therapy to adults and minors.

The bill passed on the last day of the legislative session after the House agreed to accept the Senate’s changes to the law. The Senate's major change was an amendment requiring public school administrators to report students to parents if they were identifying as a different gender from their assigned sex or using different pronouns.

“We had all these people screaming at us, we hated kids, we hate children, that we don’t care about the emotions of kids” Sen. Josh Kimbrell (R-Spartanburg) said. “But why we’re here is because we love kids. We care about them, we care about protecting them.”

Opponents said the bill would be a forced outing and could be dangerous for children not yet ready to tell their parents if they were transgender. Still, legislators pushed for it, saying that parents had the right to know if their children were identifying as a gender different from their sex.

While some legislators said the bill was designed to protect children, others say otherwise.

South Carolina State Rep. Rosalyn Henderson-Myers (D-Spartanburg) and local advocates, including Jodi Snyder, program director of Uplift Outreach Center, and Amberlyn Boiter, president of PFLAG Spartanburg, held a press conference following McMaster's ceremonial signing.

"This bill that was signed today is an attack on families, it's an attack on our children," Henderson-Myers said.

Snyder, who works with LGBTQ youth through the outreach center, said the organization has seen an "uptick in suicidal ideations and much more need for mental health services" since the bill was introduced this year. The outreach center provides mental health support and community for LGBTQ youth.

Looking ahead at what's next for transgender youth, Boiter said there are organizations, such as the Campaign for Southern Equality and Planned Parenthood, working not only to help provide transgender youth with out-of-state medical care but are also considering challenging the legislation in court. Challenges to similar laws in southern states such as Tennessee and Kentucky are taking place.

"We will never stop working to make sure that you continue to be supported and cared for. We will not rest until you and your families are made whole again. And we can call South Carolina a safe and free place to live," Boiter said, speaking directly to the state's transgender youth.

Savannah Moss covers politics for the Greenville News. Reach her at [email protected] or follow her on X @Savmoss.

This article originally appeared on Greenville News: McMaster signs ceremonial bill banning puberty-blocking therapy in SC

South Carolina Gov. McMaster signs bill outlawing transgender care for trans youth

South Carolina Gov. Henry McMaster signed a bill banning certain medical care for transgender youth on Tuesday.

House Bill 4624, called the “Help not Harm” bill by legislators, prohibits anyone under the age of 18 from receiving gender reassignment surgery or any form of puberty-blocking or hormone therapy. The bill became effective immediately.

The bill also makes it a felony to perform gender reassignment surgery on those under the age of 18.

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McMaster said a ceremonial bill signing with legislators would take place in the Upstate next week.

Under the new bill, minors can still be prescribed puberty blockers or hormone therapy to treat certain conditions like precocious puberty or endometriosis.

The new law also bans the South Carolina Medicaid program from providing coverage for gender reassignment surgery or hormone therapy to adults and minors.

The bill passed on the last day of the legislative session after the House agreed to accept the Senate’s changes to the law. The Senate's major change was an amendment requiring public school principals and vice principals to report students to parents if their child informed officials that they were identifying as a different gender from their assigned sex or using different pronouns.

More: As SC legislature winds down, bill banning transgender youth medical care returns to House

Opponents of the amendment argued the measure would be a forced outing and worried it could put a child in an uncomfortable or potentially dangerous situation if their parent or guardian were not accepting. Supporters of the amendment said parents have a right to know if their children are identifying as transgender or requesting to change their pronouns.

Dr. Elizabeth Mack, president of the South Carolina chapter of the American Academy of Pediatrics testified against the bill during a Senate medical affairs subcommittee in February, noting there are “less than 2,000 trans kids in the state.”

Still, supporters of the bill pushed for it, saying its intention was to protect children, while others say it does the opposite.

“We stand in grief and solidarity with LGBTQ South Carolinians, who are increasingly under attack by our own government,” Executive Director of ACLU South Carolina Jace Woodrum said in a statement on X, formerly known as Twitter. “We can put to rest the notion that the government cares about limited government and personal freedom. With a stroke of a pen, he (McMaster) has chosen to insert the will of politicians into healthcare decisions, trample on the liberties of trans South Carolinians, and deny the rights of the parents of trans minors.”

South Carolina joins 25 states to outlaw transgender care for minors. It was also one of the only states that did not have a ban on transgender care in the South, with Virginia now being the lone Southern state with access.

Savannah Moss covers politics for the Greenville News. Reach her at [email protected] or follow her on X @Savmoss.

This article originally appeared on Greenville News: South Carolina Gov. McMaster signs bill outlawing transgender care for trans youth

The South Carolina statehouse, where Gov Henry McMaster delivered his "last call" executive order speech during a COVID press conference at the State House in Columbia, S.C. Friday, July 10, 2020. Beginning Saturday, July 11, 2020, South Carolina's 8,000 restaurants, bars, breweries and other establishments will be ordered to stop serving alcohol nightly at 11 p.m., Gov. Henry McMaster said at the press conference.

Posted by Richard Willett - Memes and headline comments by David Icke Posted on 28 May 2024

Nurses suing nhs trust after being forced to share women’s changing room with biological male.

NHS chiefs are facing landmark legal action after 26 female hospital nurses protested about being forced to share a women’s changing room with a transgender colleague who is biologically male. The Mail has more .

The women complained that the transgender nurse – who has not had gender reassignment surgery – had taken a “keen interest” in female staff when they were getting undressed. They say they have found the situation “intimidating and upsetting”. In a formal complaint, the nurses say they were stunned after the “sexually active” trans nurse admitted to trying for a baby with a female partner and had stopped taking female hormones. But a human resources manager at the hospital trust allegedly said that the female nurses need to “be more inclusive”, “broaden their mindset” and “be educated and attend training”. Six of the nurses are taking legal action at an employment tribunal against the NHS trust in the North East for alleged sexual harassment and sexual discrimination in what is thought to be the first case of its kind. One of the nurses told the Mail on Sunday : “We don’t feel safe because we strip down to our underwear and [the individual] doesn’t just stay by his locker. He walks around the changing room in his boxer shorts.” Another nurse said she was “close to tears” during one incident in the changing room. She said: “I was rummaging in my bag trying to find my lanyard and keys for the locker when a man’s voice behind me said, ‘Are you not getting changed yet?’ I found my keys and opened my locker and I was asked again, ‘Are you not getting changed yet?’” The woman, who was sexually abused as a child, has posttraumatic stress disorder and struggles to be alone around men. She said: “He stood there, two metres away from me, with a scrub top on and with tight black boxer shorts with holes in them and asked a third time whether I was getting changed yet.

“Flight or fight mode kicked in but I felt glued to my seat, I could not move. My hands started to sweat. I was petrified and felt sick and began hyperventilating.”

Read More: Nurses Suing NHS Trust After Being Forced to Share Women’s Changing Room With Biological Male

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In conclusion, "Forced Gender Reassignment" by Cattle Decapitation serves as a call to action, urging listeners to confront their own biases and prejudices surrounding gender identity. By using shock value and explicit imagery, the band challenges us to look beyond the gore and engage in meaningful conversations about the struggles faced by ...
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Published May 11, 2023. Updated March 12, 2024. David Reimer was born a boy in Winnipeg, Canada in 1965 — but following a botched circumcision at the age of eight months, his parents raised him as a girl. Facebook Although David Reimer's story was initially seen as a success by his family and Dr. John Money, his story would eventually prove ...
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The song's title, "Forced Gender Reassignment," immediately grabs the listener's attention and provokes a reaction. It addresses the alarming reality of some countries and societies where transgender individuals face discrimination, violence, and even forced transition surgeries. Through their brutal and satirical approach, Cattle ...
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"With that video; for 'Forced Gender Reassignment' - it was a curiosity thing. It's quite literally one of, if not the most brutal, horribly disgusting music video of all time. You couldn't find it on youtube anywhere but there were reaction videos to it! The funny thing to me is - this has all been done before.
"A Really High Hurdle": Japan's Abusive Transgender Legal Recognition
Transgender people were forced to have their sex reassignment surgeries performed in other countries until the 'Japanese Society of Psychiatry and Neurology' established requirement guidelines ...
Cattle Decapitation: Forced Gender Reassignment (Music Video 2012)
Cattle Decapitation: Forced Gender Reassignment: Directed by Mitch Massie. With Josh Elmore, Derek Engemann, Klint Lucas, Dave McGraw. Cattle Decapitation's Forced Gender Reassignment is an incredibly graphic and brutal 5 minute short film which focuses on 3 people who get abducted during a anti-gay rally, only to awake in a filthy basement and get mutilated and tortured by a masked freak.
David Reimer and John Money Gender Reassignment Controversy: The John
In the mid-1960s, psychologist John Money encouraged the gender reassignment of David Reimer, who was born a biological male but suffered irreparable damage to his penis as an infant. Born in 1965 as Bruce Reimer, his penis was irreparably damaged during infancy due to a failed circumcision. After encouragement from Money, Reimer's parents decided to raise Reimer as a girl.
The Gender Reassignment Controversy
When he was 14, Reimer began the process of reassignment to being a male. As an adult, he married a woman but depression and drug abuse ensued, culminating in suicide at the age of 38 (1). Money's ...
[Exclusive] Cattle Decapitation Release What Might Just Be The Most
Travis Ryan "For the Forced Gender Reassignment video I wanted something mean and cruel and flat out disturbing.It seems nowadays you have to be over the top in your presentation to get anyone ...
Most state bans on gender-affirming care for trans youth still ...
Opponents of trans rights have argued that kids are ill-equipped to decide on gender-related medical interventions. Those arguments largely confuse what gender-affirming health care for youth is.
David Reimer
David Reimer (born Bruce Peter Reimer; 22 August 1965 - 4 May 2004) was a Canadian man raised as a girl following medical advice and intervention after his penis was severely injured during a botched circumcision in infancy.. The psychologist John Money oversaw the case and reported the reassignment as successful and as evidence that gender identity is primarily learned.
Forced to be a Girl: The Tragic Life of David Reimer
In this video, we uncover the dark and controversial story of David Reimer, a boy who was forced to live as a girl following a medical accident and unethical...
Gender-affirming surgery
Gender-affirming surgery is a surgical procedure, or series of procedures, that alters a person's physical appearance and sexual characteristics to resemble those associated with their identified gender.The phrase is most often associated with transgender health care and intersex medical interventions, although many such treatments are also pursued by cisgender and non-intersex individuals.
A Perfect Daughter: Gender Reassignment by Gillian Laub
August 26, 2013 7:00 AM EDT. N ikki was born Niko. A biological boy at birth, she began at the age of 10 the complicated transition to becoming girl. With the utmost support of her family and ...
Forced Gender Reassignment Tab
Forced Gender Reassignment Tab. Forced Gender Reassignment. Tab. Difficulty (Rhythm): Revised on: 12/9/2023. Cattle Decapitation. Get Plus for uninterrupted sync with original audio. 100%.
A poor bill of health. Systemic barriers and prejudice are increasingly
The difficulty is in doctors being forced to shoulder responsibility, which makes them afraid of breaking the law and losing their medical licence or job." ... While such transphobic refusals are technically illegal, punishing such discrimination is difficult as the gender reassignment law is so vague, Coming Out's lawyer told Novaya Europe.
Toward an Intersectional Approach to Sexual and Reproductive Health
Challenges in ensuring access to Brazil's Unified Health System (SUS) for transgender individuals include discrimination in healthcare services, the pathologizing of transgender identities, and the requirement of gender-reassignment surgery as a criterion for access.These barriers, coupled with the absence of specific primary care policies ...
SC governor again signs bill banning gender-affirming care, but this
The law also bans the South Carolina Medicaid program from providing coverage for gender reassignment surgery or hormone therapy to adults and minors. ... Opponents said the bill would be a forced outing and could be dangerous for children not yet ready to tell their parents if they were transgender. Still, legislators pushed for it, saying ...
South Carolina Gov. McMaster signs bill outlawing transgender ...
The bill also makes it a felony to perform gender reassignment surgery on those under the age of 18. ... Opponents of the amendment argued the measure would be a forced outing and worried it could ...
Maelle Jacques, transgender track star, fuels push in N.H. to ban
On Gov. Chris Sununu's desk is House Bill 1205, a Fairness in Women's Sports measure that would bar boys from girls' scholastic sports in grades 5-12 based on sex at birth.
Nurses Suing NHS Trust After Being Forced to Share Women's Changing
NHS chiefs are facing landmark legal action after 26 female hospital nurses protested about being forced to share a women's changing room with a transgender colleague who is biologically male. The Mail has more. The women complained that the transgender nurse - who has not had gender reassignment surgery - had taken a "keen interest" in female staff when they were getting undressed.