Diversity, Inclusion and Equity, Government, Public Health

Transgender is not a binary issue

October 24, 2018

Why does the administration want to make it one?

After I finished my MPH program, I worked in Detroit at Wayne State University School of Medicine for two years. Wayne State was a center of excellence for people seeking sex reassignment surgery. I audited a fascinating course on issues around transgender surgery, taught by a physician in the department of psychiatry. Each week, one or more patients seeking sex reassignment surgery talked with the class of medical students. Although it was many years ago, I’ve never forgotten the way each patient reported having felt, from a very young age, that they had been born into the wrong gender. They were incorrectly assigned. This was not a whim. They had experienced throughout their lives the pain of being misclassified. It was real and poignant. Those who chose to have surgery went through severe hormonal changes, the stress of telling families, fear of being rejected, loss of jobs, in some cases, significant out-of-pocket expenses and more. Each patient engaged in extensive counseling and a substantial period of preparation. They did this, because they felt compelled to do so. What I feel for individuals in these situations is empathy, not antipathy, and I would prefer that our government responded similarly.

Transgender refers not only to people who have transitioned to a different gender or are contemplating or undergoing such a transition, but also to those whose gender identity is different from their anatomy but who choose not to have surgery. An article in a Wikipedia series on transgender topics says, “Transgender people have a gender identity or gender expression that differs from their assigned sex. Transgender people are sometimes called transsexual if they desire medical assistance to transition from one sex to another.”

Most recent estimates indicate that about 1.4 million American adults identify as a gender other than the one they were assigned at birth; estimates for youth are not available. However, the numbers would have wide confidence limits, because there are no national data from which estimates can be draw with accuracy.

According to the American Psychological Association webpage on Transgender Identity Issues in Psychology, “Many transgender and gender-variant people experience stigmatization and discrimination as a result of living in a gendered culture into which they often do not easily fit. They may not only experience an inner sense of not belonging but also discrimination, harassment, sometimes lethal violence and denial of basic human rights.”

Gender is not a binary concept of males and females. As the nonprofit organization Gender Spectrum explains about understanding gender,

Most societies view sex as a binary concept, with two rigidly fixed options: male or female, both based on a person’s reproductive functions (genitals, sex chromosomes, gonads, hormones, reproductive structures). But a sex binary fails to capture even the biological aspect of gender. While most bodies have one of two forms of genitalia, which are classified as “female” or “male,” there are naturally occurring intersex conditions that demonstrate that sex exists across a continuum of possibilities. This biological spectrum by itself should be enough to dispel the simplistic notion of the “Gender binary”- there are not just two sexes.

Regarding a gender spectrum, Dr. Anne Fausto-Sterling writes in The New York Times, “what matters…is not the presence or absence of a particular gene but the balance of power between gene networks acting together or in a particular sequence” following 1950s psychologist John Money’s model of sexual development. Even from a biologic perspective, the oversimplification of gender is unfair, and proposed actions are, to my mind, as a non-lawyer, discriminatory.

The current administration in Washington is stepping up its campaign against civil rights for transgender people. If there is a problem to be solved, it has not been articulated clearly. They have made transgender rights one of their issues, and apparently are seeking to remove legal protections for transgender people. German Lopez, writing in Vox, said, “The Trump administration’s move would declare that federal sex discrimination bans do not cover trans people. This would not only flip the Obama administration’s move to protect trans people but would also attempt to apply the anti-trans interpretation across the entire federal government from this point forward. If allowed by the courts, that would ensure that future implementation of federal civil rights laws leaves trans people behind.”

As a heterosexual white woman, I do not want the government in this business. I want them working on issues of global security, including climate, and the big drivers of economies, health, and mortality. This is not one of them. As a member of the North Carolina Department of Administration’s Commission on Inclusion (for whom I am not speaking), a public health professional and educator, a civic-minded American and a human being, I’m committed to advancing policies that promote inclusion and equity and protect everyone against discrimination. I am proud of the work North Carolina Governor Roy Cooper has done to build a more inclusive workforce.

We can be an inclusive society and recognize that, for some people, there is a difference between the sex on their birth certificate and the gender with which they identify. They should be entitled to the same protections as others in our society.

The views expressed in this blog are Barbara Rimer’s alone and do not represent the views and policies of The University of North Carolina or the Gillings School.




Thanks so much for writing. I agree with you and Derrick Matthews that removal of rights is a major threat, and it's particularly cruel and unfair to deny eople rights they were given only a few years ago--which they should have had all along. Barbara

Helena Knego


Great post! It disturbs me greatly that the current US president has talked about removing protections for trans and non-binary people, a population that is already vulnerable in many ways. I couldn't agree more that I want the government to spend its time on important global and national issues rather than taking away anyone's civil rights. I worry that trans people who were emboldened to be out by the protections offered by the Obama will now be at risk. I appreciate both Dean Rimer and Dr. Matthews speaking up with evidence and a sense of justice about this important issue. Thank you!

Barbara Rimer


Thanks so much Derrick! I could not agree more!

Derrick Matthews


There are so many assaults on the health and well-being on transgender persons all over the world. To say the least, it's disheartening to see our own government once again take unnecessary steps to attack the fundamental humanity of persons who exist outside a gender binary. As a School of Public Health it's so important that we fulfill our obligation to acknowledge how these efforts not only have no basis in science, but serve to exacerbate the already stark health inequities* experienced by transgender communities across the country and here in North Carolina. To enact a policy change that will adversely impact the health of millions of people for no reason is nothing short of cruel. Thanks for drawing attention to such an important issue. *Some references for those who want additional information about transgender public health are below. Grant, J. M., Mottet, L. A., Tanis, J., Harrison, J., Herman, J. L., & Keisling, M. (2011). Injustice at every turn: a report of the national transgender discrimination survey. Washington, DC: National Center for Transgender Equality and National Gay and Lesbian Task Force, 2011. James, S. E., Herman, J. L., Rankin, S., Keisling, M., Mottet, L., & Anafi, M. (2016). The Report of the 2015 U.S. Transgender Survey. Washington, DC: National Center for Transgender Equality. Reisner, S. L., Poteat, T., Keatley, J., Cabral, M., Mothopeng, T., Dunham, E., ... & Baral, S. D. (2016). Global health burden and needs of transgender populations: a review. The Lancet, 388, 412-436. Stroumsa, D. (2014). The state of transgender health care: policy, law, and medical frameworks. American journal of public health, 104, e31-e38.

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The views expressed in this blog are Barbara Rimer’s alone and do not represent the views and policies of The University of North Carolina or the Gillings School.