Let’s try a thought experiment... here are some different accounts about how transsexualism might come about:

1 Inborn psychological gender identities and differences exist:

1.1 Transsexualism is caused by natural biological processes shaping gender identity before birth. The brain and the subconscious gender identity develops towards one gender, the physical sex of the body develops towards the other gender. Psychologically, transsexuals are similar to their experienced gender.

1.2 Transsexualism is a social and cultural phenomenon, caused by upbringing and experiences early in life. The gender identity of the individual is socially programmed to one specific gender (opposite to the physical sex of the body), and has nothing to do with physiological causes of gender identity.

1.3 Transsexualism is a mental illness which produces delusions and hallucinations. It has nothing to do with physiological causes of gender identity.

1.4 Transsexualism is a type of misdirected sexual orientation, similar to a fetish. It has nothing to with physiological causes of gender identity, it is about sexual fantasies, getting excited about oneself in a body of the other gender.

2 There is no such thing as a natural biological gender identity. Men and women are identical in all mental respects; differences in gender identity, gender role or expression are purely cultural constructs.

How would you treat a person that has such a condition? Would you treat the person exactly the same, no matter whether cause 1.a, 1.b, 1.c, 1.d or 2 applies?

In a way, the answer has to be yes. All people deserve our respect, and all people deserve a certain quality of life. If people suffer, we ought to help them, and society is obliged to create norms and processes that diminish suffering.  That is basic human decency and is also best for society since it probably optimises well-being.

For all four examples, the question then has to be about the best way to help the individual. We have to research, examine and test what interventions are able to reduce the suffering of transsexuals. So far, the approach is the same. After that, I think the similarity falls apart.

I’ll try to illustrate that with narratives how transsexuals might get treated in a modern, tolerant, liberal society. You might disagree with me on certain points or you might imagine an ideal society – but I do think reactions do differ based on the cause/the background information available.

1.2 Caused by social environment: In this case, transsexuals simply had a gender-variant upbringing and confusing experiences. They are mistaken about their gender identity, which reduces quality of life. Society would probably have a duty to help, as in other cases where children have a deficient upbringing. The first approach would be therapy to bring the experienced gender identity back in line with the birth-assigned gender, clearing up the confusion. If this doesn’t work, there might be other support programmes, but public opinion would be divided, just as it is over the treatment of criminals or anti-social youths with a bad childhood. Since the experienced gender identity of transsexuals exists only in their heads, society wouldn’t fully accept the desired gender role. After all, life is not a bowl of cherries, and why should some people get special treatment? Transsexuals simply have a fixed, mistaken idea about reality, and the right response to that is a shaking of the head, not playing along.

1.3 In the case of transsexualism being a mental illness, our priority approach would be to cure it, either by therapy or drugs, so that the person can live happily in their birth-assigned gender role. It’s probably our moral obligation to connect the person back to reality and do away with delusions.

If there is no cure available, we’d try to alleviate the symptoms, either by therapy, drugs or other interventions. Since the person is ill, health insurance/society has the duty to help.

Naturally, mentally ill people are allowed to live freely in our society if they don’t pose a danger to others or themselves. When dealing with a transsexual we wouldn’t necessarily feel obliged to play an affirming or active role in the delusion (i.e. to accept their chosen gender role), but we might play a little pretend to make the poor person happy. However, we wouldn’t afford the judgement and opinions of the affected person the same weight we attach to psychologically healthy individuals and reduce our expectations regarding responsible social behaviour, giving in effect a jester's license.

The general thinking would be along the lines of: “this poor man is insane, he thinks he is a woman, there is no cure for it, so we have to play along to make him happy”. I don’t think society would accept this person fully and equally in their chosen gender role.

1.4 Sexuality is usually seen as a private matter. Sexual orientation, fetishes and sexual deviancy are accepted in a tolerant society as long as they are harmless and kept within the personal space. As a member of the public, I have no obligation to take part in someone else’s sexual fantasy and desires. As a partner of a transsexual, my obligation is to play along happily within reason, in the same way I expect my partner to respect my sexual wishes.

Society or health insurance has no obligation to support or help – they don’t pay for a BDSM dungeon or sex toys either. Support is required only if the sexual fantasy turns into a harmful obsession, in which case number 3 applies (mental illness). However, the support won’t be simply fulfilling the sexual fantasy, as this is not a healing approach and probably not accepted by society.

General thinking would be along the lines of: “this guy is sex-crazy, he has deviant sexual interests – good for him as long as it’s harmless, but I don’t want anything to do with it”. I don’t think society would accept this person in their chosen gender role at all.

2 Society should get rid of the oppressive and artificial gender roles and differences. People should not be categorised according to the traditional gender dichotomy. Ideally, everybody moves within a big androgynous spectrum without any differences. If people feel a need to label themselves in terms of gender categories, they can do so freely, without any judgement from others. Transsexuals are mistaken about their feeling of belonging to a particular gender; their body dismorphia has no physiological reason, it’s simply caused by cultural constraints. Even worse, transsexuals might be either dinosaurs clinging to outdated sexist standards, or poor saps who fell hook, line and sinker for sexist propaganda and are now useful tools for the dominant group. Society or health insurance has no duty to help.

General thinking would be: “This person can dress and act in any way they like, but they shouldn’t say they feel like a particular gender or have certain gender-specific traits. They should simply stop making a deal out of it, there is no such thing as gender.”

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