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Picture by Evie Shaffer

Content note: this essay uses neutral they/them pronouns to refer to trans women, and the term “male trans people” for trans women, transfeminine people, & other varying dmab trans people. It also contains graphic discussion of male violence.

I woke up this morning to an anonymous message from someone expressing they sincerely hope that someday my opinions on trans women change. The reason given was so simple — my opinions are hurting a lot of people, presumably trans women. This really struck a chord with me. It’s so much more honest than the usual accusation that my opinions are killing trans women, which is so far outside of reality that arguing against it is futile, especially since the opinion-holder usually can’t hear me correctly through all the cognitive dissonance. But hurting trans women? This, I can speak about.

Let’s talk about pain. There is a reflexive, very human (societal) response to dehumanize people who we see as in opposition to us in some way. Whether political/ideological enemies, someone who has caused grievous emotional/sexual/physical harm to us, or a group of people we hold bias against, there is a flattening of them as a complex human being. We do not think of them as a whole person who suffers, delights, and experiences the full spectrum of emotion. We think of them as a monster. Or a piece of shit. Subhuman. Thinking of them this way does not change that they have thoughts and feelings too.

I’ll start with incels. On on incels.net, a popular forum for self-identified incels, scrolling through the search results for “sadness” is a never-ending parade of men expressing deep unhappiness, body image issues, loneliness in the extreme, & fear of a pointless existence. These men are hurting. The documentary Shy Boys is an even more undeniable display of obvious misery. Even as they spout misogynistic drivel, just seeing these men from 20 feet away would betray how uncomfortable they are in their skin and the world at large. The first incel murderer Elliot Rodger’s manifesto, My Twisted World, starts with this:

“Humanity… All of my suffering on this world has been at the hands of humanity, particularly women. It has made me realize just how brutal and twisted humanity is as a species. All I ever wanted was to fit in and live a happy life amongst humanity, but I was cast out and rejected, forced to endure an existence of loneliness and insignificance, all because the females of the human species were incapable of seeing the value in me.”

So everyone hurts. Everyone suffers. Do rapists not cry in court? I regularly refer to rapists as monsters. I do not think of them as human in the same way I am. My brain’s natural inclination is to exercise the flattening of their reality to make my own easier to bear. But when approaching the issue of emotional pain intellectually, I am able to recognize that experiencing emotional pain is almost ubiquitous among humans, except in extreme, poorly understood cases. So if everyone hurts, we come to an intense question to ask ourselves: Whose pain takes precedent? How do we measure?

I will not deny I cause trans women emotional pain. Let me give you an example: a few years ago, when it was uncovered that a celebrity trans woman who is very active in youth organizing is a serial rapist, there was a large push from a few women for their victim’s testimony to gain traction. This “trans icon” is at large in a city that is very trans & queer friendly. Due to their celebrity status, they have a large amount of victims to pick from. They prefer transmasculine & trans men victims, that is to say, female trans people. A leftist trans woman with a large audience who lived in the same area as the serial rapist was approached about spreading the word about this active predator. They did momentarily, but then deleted the information as they decided the information had been posted by a TERF. I began to rail against them. I made several posts about how rape apologism in the queer & trans community is out of control, how male people stick up for their own, & how disgusting it was that they would choose TERF war politics over a very real opportunity to warn potential trans rape victims about a powerful predator. I cried myself out and went to sleep.

The next day, my messages were full of angry people demanding I stop harassing trans women. I checked the leftist’s trans woman’s blog and they had written at length about how intensely dysphoric and suicidal interactions like this made them, and how in particular discussions about male violence from trans women made them feel like a disgusting monster who would never be a real woman or fit in. My anger hurt this trans woman deeply. They were suffering. Of course, this incident was picked for the purposes of my essay. The point remains that you can hurt someone by saying something that’s true. I do not regret my actions, nor do I feel sympathetic towards this person’s pain. I can understand they were emotionally wounded without accepting myself as the emotional tormenter they proclaimed me as.

You can cause pain by setting boundaries that protect yourself. To the one who wanted in, the boundary is experienced as a wall of rejection. To be unwelcome somewhere you desperately wanted to belong hurts. It causes emotional pain to male trans people to be aware that myself and other female people actively organize without them. That we have spaces both online and in real life where we can go to talk to each other freely without male presence about anything we desire. That we can politically strategize around our female experiences, that we can consciousness raise around our female suffering, that we even have some spaces where we talk about the harms male trans people in particular have done to us.

So why not stop? Why is the sadness of trans women not enough to sway us? Why is the loneliness, sexual frustration, and romantic dejection of trans male people who want to date & fuck lesbians not enough to shut us down? Why?

Now I will say something forbidden by patriarchy: What about my pain? Or: what about our (female) pain?

What about my pain? Here is a situation in which I had to measure my pain against a trans woman’s pain.

Sometime in 2013, I was driving with my trans girlfriend of 3 years. They were angry with me. We parked in a parking lot. They became more angry with me because I talked back. I do not remember what the fight was about. From the passenger seat, they lunged at me and slammed my head three times against my driver’s side window. I became dazed. My vision blurred. My cheek was bleeding from their nails. My hearing was foggy. As I turned to look at them, I saw their face fall and the tears gathering in their eyes. Numbly, I reached for them. I held them as they cried. They were sorry (as domestic abusers often are). They were experiencing intense self-hatred, self-disgust, and sadness. I pet their hair and told them everything was going to be okay until I had to open my door and throw up.

When we were breaking up a year later, this incident became a fixture in our fights. I couldn’t stop bringing it up. “I held you,” I would scream, “after you gave me a concussion! I held you and I told you it would be all right!” This hurt my trans girlfriend. This incident had caused them a lot of pain. It hurt them to be reminded they had done this to me. It hurt them that I insisted on still being upset about it a year later. It hurt them that I would bring it up after being told that bringing it up caused them a lot of pain. It hurt.

I’ll ask you again: what about my pain? What about the pain of the celebrity trans woman’s victims, who watch as someone whose particular favored mode of rape is unexpected, non-consensual fisting — the act of shoving one’s hand into a vaginal canal, resulting in incredible pain, tearing, & bleeding continues having status as a “queer icon” with little repercussions? What about the pain of other female people I know who have been sexually assaulted by trans women and remain largely silent, watching what happens to those who speak out about being preyed on by male trans people, the unavoidable meltdown in the surrounding friend group, the possible professional repercussions on top of the social ones? I could endlessly go on linking news stories and sharing painful testimonies, but I know by now the sheer volume & undeniable pattern of these events will not sway those who will not be swayed.

So let’s change the subject, because certainly not all trans women are rapists. I have never and will never say this, no matter how many times I’m accused of it. So let’s pretend there’s not an epidemic of male violence by trans women against female people within the trans & queer community, an epidemic for the basis of which is written as clearly into trans ideology as rape culture is into patriarchal values. Let’s pretend that the issue is solely one of exclusion, as in, trans exclusionary radical feminism.

A lesbian (a female person who desires other female people) wants to gather with other lesbians. She has a small group of ten lesbians. A female-attracted, lesbian-identified male trans person wants to come. The lesbian says no. The trans woman is hurt they were rejected. The lesbian is hurt because her boundaries as a lesbian were disrespected. Other lesbians in the group are hurt, some for the same reason as the leader, and some because they are hurt on the trans woman’s behalf. The lesbians begin to be hurt by each other because they are in disagreement over male inclusion in a lesbian space. The trans woman tells all their friends what happened and they are hurt on the trans woman’s behalf and on their own behalf as trans people. They begin to communicate with the group of lesbians, condemning their hurtful behavior with varying degrees of shame, rage, disappointment, pleading & threats. Some of the lesbians are hurt by the content of this communication, hurt at their lesbian sexuality and boundaries being disrespected and maligned.

How do we measure all this pain? Whose pain matters?

In most circles of trans activism, this question is forbidden. The lesbian’s pain is not acknowledged as pain. It is dismissed outright, without hesitation, as bigotry of the worst kind. It is dismissed more easily and with more completeness than the media response to murders by angry, lonely white men. The humanity of a female person who wants to gather with other female people is gone in the blink of an eye. The humanity of a lesbian who explictly says she is not interested in male trans people romantically or sexually is erased. Now, she’s just a TERF, who deserves what all TERF deserve.

TERFs are incapable of pain. TERFs are removed from the section of humanity that have complex reasons for the actions they take, the words they speak, and the viewpoints they hold. TERFs do not have rich emotional landscapes or varied interests. TERFs are not people (certainly not lesbian or women, either.)

So of course, the trans woman’s pain is the pain that matters, because TERF (read: female, read: lesbian) pain is not truly even a factor.

I don’t see it that way any more. And there is nothing I am more grateful for. Part of the deprogramming of trans & queer ideology was re-learning to recognize, accept, & value my own and other’s female pain. This was a shock to me as someone who identified privately as a feminist even as a child in a Baptist fundamentalist household, who spit the word chauvinist out regularly before the age of 10, having learned it and kept it in my heart as the most hateful of curses against a boy or man, a man-hating baby dyke who raged against the unfairness of it all. But trans ideology was the perfect trap.

Trans ideology said: these male people are not men. They are just like you. If you think of or treat these people as men (or male), you are actively contributing to the oppression, suicide, and murder of the most vulnerable women alive, trans women. By the way, this includes thinking of any of their (male-patterned) behavior as male, being uncomfortable in any way, or not immediately and enthusiastically including them in your lesbian sexuality. I took it to heart, and that’s how I ended up in that hot car, stroking my trans girlfriend’s long hair, knowing that this couldn’t be a truly abusive situation, because the power dynamics between a dfab trans person and a trans woman wouldn’t allow it.

I hurt trans women. I hurt trans women when I name them as male people. I hurt trans women when I talk about the trans women who abused me. I hurt trans women when I talk about how the ideology of trans activism is fundamentally woman-hating. I hurt trans women when I talk about how male people identifying as lesbians is inherently lesbian-hating. I hurt trans women when I talk about the trans women who rape and murder. I hurt trans women when I won’t change my mind. I hurt trans women when I won’t shut my mouth about how trans women hurt me. I hurt trans women. I do.

Authorities are seeking a man who they say lured a 12-year-old girl into a public restroom and raped her.Southside Place Police Department

Authorities are seeking a man who they say lured a 12-year-old girl into a public restroom and raped her. 

The sexual assault occurred earlier this month in the bathroom of a CVS location in the 3900 block of Bellaire Blvd. in the Southside Place area, just south of West University.

Southside Place police released details of the assault this week to local media. They also released surveillance images.

It’s believed the person of interest is a male in his ‘20s. The victim was reported to be just 12 years old.

Police tell the Houston Chronicle that the girl went into the bathroom after the man and that’s when the assault occurred. He reportedly told her that he was 27 years old. 

The girl was at the store with her mother, police say. 

Parents in the area were mortified to hear of the incident, according to KPRC-TV. 

That suspect is still at large and locals are hoping he’s caught soon.

Anyone with any information on the incident or the suspect is asked to contact Det. Mike Kelly with the Southside Place Police Department at 713-668-2341.

Meanwhile Kelly is coming under fire from an author at Jezebel for making a seemingly insensitive comment on the case this week when speaking to local media.

A Mayo Clinic study has shown that hysterectomy without removal of ovaries increases the risk of heart disease. Women who had a hysterectomy before age 35 are at a particularly high risk. Specifically, their risk was 4.6-fold for congestive heart failure and 2.5-fold for coronary artery disease. But this association is not new. This 1981 study showed a 3-fold increased risk of heart disease after a premenopausal hysterectomy. This would include most women who undergo hysterectomy. This 1982 study and this one from 1985 cite the uterine substance prostacyclin as the likely factor in women’s heart health. Since about 45% of women have a hysterectomy, it is no wonder heart disease is the #1 killer of women!

Heart Disease: Just the Tip of the Iceberg

Hysterectomy is bad for much more than the heart.

Hormone changes. Hysterectomy impairs the function of the ovaries which are part of the endocrine system. Multiple studies have shown this including this one and this one. This would logically predispose hysterectomized women to the same increased health risks and accelerated aging of ovary removal (castration). According to numerous studies such as this one and this Mayo Clinic one, the risks of ovary removal include heart disease, stroke, metabolic syndrome, osteoporosis, hip fracture, lung cancer, colorectal cancer, dementia, Parkinsonism, impaired cognition and memory, mood disorders, sleep disorders, adverse skin and body composition changes, adverse ocular changes including glaucoma, impaired sexual function, more severe hot flushes, and urogenital atrophy. Wow, what a list for such a common and rarely necessary surgery!

Figure changes. The uterus and its ligaments are key to the integrity of the pelvis. The cutting of those ligaments, the pelvis’ support structures, destroys pelvic integrity. As a result, a woman’s figure changes. The hips widen and the torso collapses until the rib cage sits directly on the hip bones. This causes a shortened and thickened midsection, protruding belly, and loss of the curve in the lower back making the derrière appear flat. These changes lead to back, hip, and leg problems, chronic pain, and impaired mobility. These effects are discussed here. Back pain after hysterectomy is one of the (many) “dirty little secrets” of Gynecology.

Organ dysfunction. The uterus sits between the bladder and bowel and keeps them where they belong. Hence, these organs drop and are adjacent to each other after hysterectomy. These changes can cause dysfunction as discussed here and here.

Sexual dysfunction. The uterus is a sex organ. Many hysterectomized women report a loss of sexual function – libido, arousal, and ability to orgasm – with or without ovary removal. Many also report feeling asexual and emotionally empty. This may explain why a renowned gynecologist referred to the uterus as a woman’s “heart center.” How ironic that the uterus is also essential to heart health!

Cancer risks. Last but not least, removal of the uterus increases the risk of some cancers. These include thyroid, renal cell (kidney), bladder, rectal and brain cancers.

The Devastating Toll of Hysterectomy

Women’s experiences are also compelling evidence of the devastating effects of hysterectomy. It can affect every relationship and aspect of life having far-reaching societal repercussions. Here, here and here are some heartbreaking stories of shattered lives. The Bleeding Edge documentary chronicles the stories of a few women who were harmed by Essure (tubal sterilization coils) and subsequently had hysterectomies. The HERS Foundation’s recently launched “In My Own Voice” project includes some women’s stories. Hopefully, more will come forward and share their experiences.

The uterus and ovaries are essential to a woman’s whole life. Female organ removal has been proven over and over again to be incredibly harmful as far back as 1912. Yet 45% of women end up having a hysterectomy. And over half are castrated at the same time which further increases the risk of heart disease. Additionally, more women have ovaries removed during separate surgeries. It is no wonder heart disease is the #1 killer of women.

Female organ removal is the biggest healthcare con as discussed here. Lack of informed consent is standard. And even worse, gynecologists commonly use unethical tactics such as instilling fear of cancer and intentionally misinforming women about the consequences. If women knew the facts, very few would consent to hysterectomy or oophorectomy.

Women's rights activist Yanar Mohammed  MADRE

In 2016, she was awarded Norway's Rafto Prize for human rights for her efforts to help minorities and women subjected to sexual abuse in Iraq.

BAGHDAD: Prizewinning Iraqi women's rights activist Yanar Mohammed was shot dead on Monday in Baghdad, her organisation said.

"At 09:00 am (0600 GMT), two gunmen on a motorcycle opened fire on her outside her residence," the Organisation of Women's Freedom in Iraq (OWFI) announced.

Mohammed was seriously injured, "and despite being taken to the hospital and efforts to save her, she succumbed to her wounds".

OWFI urged the authorities to track down the perpetrators.

Mohammed co-founded OWFI in 2003 to provide protection to women victims of violence.

In 2016, she was awarded Norway's Rafto Prize for human rights for her efforts to help minorities and women subjected to sexual abuse in Iraq.

The Rafto Foundation said it was "deeply shocked by this brutal attack on one of the most courageous human rights defenders of our time".

"The assassination represents not only an attack on Yanar Mohammed as a person, but also on the fundamental values she dedicated her life to defending: women's freedom, democracy, and universal human rights," the foundation added.

God bless our Patreon supporters. Seriously. In our April topic poll, I gave them several non-depressing softball article topics. But the one they wanted to read most was about the relationship between sexual assault and the gender wage gap. GOD. DAMN. You guys are the fucking best. We are so happy to be supported by people who are willing to embrace the difficult stuff.

The gender wage gap is a many-tentacled hentai monster. What is its primary driver? Is it choice of career? Education? Lack of mentors and sponsors? Familial commitments? The high cost of childcare? Lopsided domestic duties? Ingrained sexist attitudes in the culture? Unconscious bias during the hiring process? Biological differences in the brain?

Research demonstrates that it’s almost certainly a gnarly combination of all of the above. But there’s another element that doesn’t get much attention, and that’s fear of rape and sexual assault. Harassment and isolation are known contributing factors for so-called “pipeline” problems, but I’m talking about something that goes even beyond that. There are instances where the threat of rape acts as a professional barrier to women.

So today, we’re going to look at three different case studies: two from my own life and one from recent news. The last one is very exciting to me, because it’s basically the perfect case study for examining this issue.

This article talks about the existence of rape and sexual assault, but does not go into details about specific acts. Some linked articles do. Use that information as you will.

Case #1: Blue Collar Work

A salesman for Power Home Remodeling recently visited my home. It was a door-to-door call, which is normally a nonstarter—but I happened to be interested in the service he was offering, so I let him make his sales pitch.

I was struck by this salesperson’s energy. He looked like a college kid and was brimming with excitable-puppy energy. But even more striking was his description of the company work environment. He gabbed about a huge annual company trip to Cancun, all expenses paid. I told him it sounded like a fraternity party. “Oh, very much so, yes,” he told me earnestly, with just a hint of sheepishness. “It gets pretty wild.”

I smiled at him and said, “You must not have many women on the team.”

He shook his head. “You have no idea how true that is. A big part of selling is doing what I’m doing now—walking into stranger’s houses. Women don’t want to do that. You don’t know if you’re going into a creeper’s house alone. We’d love to have more women, but I don’t blame them for staying out of sales.”

Surprised by his candor, I pressed a little further. “Not many people of color either, huh?”

“Not really,” he said, shrugging. “We have one person on my team with darker skin—an Indian guy. He has to work ten times harder than I do to make a sale. People won’t open the door for him. I at least know that people are going to let me introduce myself, and not try to chase me off with a shotgun. So yeah, it tends to be all young white guys, for understandable reasons. Sort of a chicken-and-egg thing.”

“If it’s a known problem at the company, is anyone working on it?” I ask. “Do you have a chief diversity officer, or anyone like that, whose job it is to find ways to fix it?”

He shrugs. “I don’t really know, to be honest.”

He presses on with his sales pitch. During the pitch, he mentions that “both homeowners” really should be present. In fact, he mentions it four times. He persists even after I inform him that the house is in my name alone. When he finally relents, it is as though he’s made some kind of special exception for me.

I’m personally not nervous to have this obsequious, casually sexist stranger in my home. My two large dogs are sitting at my feet. I have my phone in my hand. My neighbor works from home, and his house is close enough that he can hear me if I scream. I know which doors are locked, which windows don’t have screens, which door frame has a baseball bat leaning against it. My home is where I feel safest and most powerful.

I’m sure this is the case with most people—including men. Which is why I instinctively avoid entering men’s homes alone, especially men I do not know. I am afraid to put myself in their power. To be explicit: I’m afraid of being physically overpowered and raped or murdered. And that is the only reason.

This fear repels me from being a door-to-door salesperson. The last time I was making door-to-door sales, I was a Girl Scout selling cookies. Even at eight years old, I had learned to conduct all business from the front porch. And maybe it’s not a big deal. I’m pretty sure I wouldn’t want to be a salesperson anyway.

But then I thought about it more. In all my years of house calls from landlords, property managers, plumbers, electricians, carpenters, cable installers, home inspectors, delivery people… I couldn’t think of a single time that it had been a woman. (Mr. Kitty says our pellet stove repairperson was a woman, SO THERE’S ONE!) Statistics back up my anecdotal experience. Women make up only 1.5% of plumbers, 1.6% of carpenters, 2.6% of maintenance and repair professionals, 3.7% of telecommunications installers… Basically, jobs that require house calls repel women.

I looked up the leading cause of death for women while on the job.

Surprise! It’s homicide.

Case #2: White Collar Work

I’ve mentioned that I work for a large technology company with a household name and an international presence. In most situations, it’s quite cool—we can have people from the American South, the Pacific Northwest, the eastern coast of Canada, Ireland, India, and Indonesia all together on one call.

One downside of this international collaboration is time zones. When I’m coming online first thing in the morning, my coworkers in Mumbai are sitting down to eat dinner with their families. It’s a complicated give-and-take; everyone at some point is required to take calls outside of their normal working hours. We tend to schedule so that the fewest number of people are inconvenienced.

Recently we ran into an issue that complicated things. We’d promoted several women in the Mumbai offices to a highly technical role that required daily interaction with engineers in America. The American engineers are by far the largest constituency on the call, so it’s scheduled on North American time.

But there is a problem. Our Indian offices have a company policy that forbids women from leaving the building after hours without a security escort.

The explicit purpose of this security escort is to deter men from raping women.

(If you’re blissfully unaware of India’s horrific national rape problem, you can read some of these sources for a rude awakening.)

This security policy ends at a certain time, because the security guards need to go home at some point. When their shift ends, all women are escorted from the building whether they’ve finished their work or not. The after-hours calls our recently-promoted Indian team members needed to take were scheduled for after the security escort’s closure.

My company still hasn’t figured out this problem. This problem isn’t unique to our offices. Businesses everywhere are struggling to address it. Right now, the women are just not making it to these calls, and they have to rely on written reports, limiting their ability to contribute meaningfully to the process.

Recently, someone floated the possibility of circumventing the problem by selecting only men for this role in the future.

Women in India make 25% less than men.

Case #3: Gig Economy Work

A recent study at Uber revealed that—controlling for all variables— male drivers make more money per hour than female drivers. 7% more, to be exact.

This flies in the face of accepted narratives about why women earn less money, because Uber removes many variables common in traditional hiring practices. There’s no negotiation for pay. Raises aren’t a thing. And the work runs on a flexible schedule by design.

Further, passenger sexism was ruled out as the cause. Riders weren’t tipping men more than women. So how was one gender still out-earning another?

Ultimately the researchers were able to identify several reasons. Half of the earnings gap was explained by differences in driving speed—statistically, men drive faster than women, allowing them to fit more passengers into each hour.

What about the other half of the earnings gap? Well, let’s split that into two reasons again. First: driver experience translates directly into higher earnings, and women quit driving at much higher rates than men. Second: men and women choose to drive in very different places, with more men congregating at locations with higher surge pricing and lower wait times.

The researchers theorize that this is due to the threat of sexual assault and violence.

The dynamic of one driver and one passenger is dangerous for women living in a culture that views their vulnerability as an opportunity. Multiple male Uber drivers have been charged with sexual assault. And multiple female Uber drivers have been sexually assaulted by their male passengers.

Driving to places with high surge pricing (like bars or shows at closing time) could make women leery of being attacked in their own car. The same holds true for driving to airports, a lucrative trip that requires women to drive through depopulated industrial areas alone with unknown passengers.

Only 27% of Uber drivers are women, and 76% of them leave the platform after six months.

“I left it at home!”

Wanda Sykes has a legendary standup bit that goes like this: what if women’s vaginas were detachable? What if you could just leave it at home?

Part of the bit describes her going for a jog after dark. A would-be rapist pops out to menace Wanda, but she shrugs and says “Oop—I left it at home! Sorry. I have absolutely nothing of value on me.” The rapist, disappointed, leaves her alone, and she continues on her imagined night jog.

I think about this bit a lot. For one, it’s breath-snatchingly funny. But more significantly, when I think about what it would actually be like, I feel an enormous sense of relief wash over me. Walking around with a female body feels like walking around with $10,000 in your pocket. You live you life in a state of CONSTANT VIGILANCE!! (Minimum one Harry Potter reference per article, part of our terms and conditions, read the fine print.)

The fear of sexual assault is so pervasive that it shapes women’s actions both consciously and unconsciously. It encompasses everything, from the jobs we seek to the places we go. As long as that fear exists, the gender wage gap will persist.

People of all genders deserve to move through the world without fear of sexual assault or the humiliation of being perceived as a potential rapist. Masculinity is not inherently violent, and femininity is not a state of perpetual victimization. These bizarre perversions exist only because our culture has a long legacy of embracing them. To change rape culture, we must change our thinking and our behavior, make concerted challenges to the status quo.

To paraphrase Eliezer Yudkowsky: “You are personally responsible for becoming more ethical than the society you grew up in.”

There are many, many things that both women and men can do to fight rape culture. And most of it isn’t pussy hats and marching with signs! Whether you’re interested in loud activism or quiet advocacy (introverts, we feel ya), somebody’s made a list of things you can do.

You can also check these classic articles from our archive:

1 Easy Way All Allies Can Help Close the Gender and Racial Pay Gap

Something Is Wrong in Personal Finance. Here’s How To Make It More Inclusive.

A disgraced South Carolina pastor was indicted on two counts of cyberstalking and making false statements to investigators after his wife died by suicide last year

A disgraced South Carolina pastor was indicted on two counts of cyberstalking and making false statements to investigators

A disgraced South Carolina pastor was indicted on two counts of cyberstalking and making false statements to investigators after his wife died by suicide last year, as she filed for their divorce.

John Paul Miller, 46, was indicted on the two counts on Thursday. Federal authorities said the man cyberstalked his wife, Mica Miller, posting nude photos of her online from November 2022 until her death on April 27, 2024.

Authorities claim that John Paul, who used to preach at Solid Rock Church in Myrtle Beach, constantly stalked his wife in the two years leading up to her death, including placing tracking devices in her car, bombarding her with unwanted messages, and even slashing her tires on one occasion.

An investigation also revealed that the man would interfere with his wife’s finances, as well as post explicit photos of her online without her consent.

Mica, who was 30 years old at the time of her death, was found dead from a self-inflicted gunshot wound at Lumber River State Park. She was an aspiring missionary and worship leader.

Mica, who was 30 years old at the time of her death, was found dead from a self-inflicted gunshot wound at Lumber River State Park.

The day after her death, John Paul announced the tragic incident at the end of her sermon.

“I’m taking a little bit of a break, and I don’t want to have to worry about the church,” he said in 2024. “My break may be a few days, a few weeks, I don’t know.”

Soon after, however, reports started resurfacing that the pastor had abused his wife, including a police report that alleged he did not let her drive and “groomed” her years before they married.

As a result, a petition created by community members claimed Mica “lost her life due to no one helping her from being harassed and excessively stalked” by John Paul, whom she was “desperately trying to get away from.”

“She made report after report, no contact order was made, and received no help, not even from law enforcement,” the petition said.

If convicted, John Paul faces a maximum of five years in prison for cyberstalking and two years for making false statements to federal investigators.

John Paul faced further scrutiny when an Indiana woman claimed he had raped her when she was 15, and he was a 19-year-old youth church leader.

On Thursday, the U.S. Attorney’s Office, District of South Carolina, released a lengthy statement announcing they had secured an indictment against John Paul, accusing the former pastor of lying to them about damaging his wife’s car, despite finding evidence that he had bought a tire deflation device and “sent messages to others regarding the victim’s vehicle.”

“Federal investigators interviewed Miller about these allegations and Miller lied in his responses. Miller said he did not damage the victim’s tires, when in fact he purchased a tire deflation device online and sent messages to others regarding the victim’s vehicle,” the statement reads.

A Handmaid's Tale Twist—Surrogacy by Rape?

In a case that’s hard to wrap your brain around, a man who raped his client while she was unconscious was granted sole custody of toddler twins born of the rape—just days before Christmas.

Another case Straight Outta Family Court!

In a twist, the rapist’s wife, who was the president of a guardian ad litem [GAL] agency used by the judge, is on board with taking and raising the twins.

The real mom feels like she’s in The Handmaid’s Tale.

It’s like surrogacy by rape, like The Handmaid’s Tale.

But this case is not so unbelievable if you are familiar with the Family Court agenda to cover up sexual assault and other forms of violence and abuse by men in order to accomplish the great custody switch. It’s par for the course.

The good news is, this Oklahoma mama got away with her babies before they could be snatched! However, the despicable, rapist-enabling judge is still pursuing them across the border in Texas.

As usual, we’ll tie this mother’s case into the broader picture in the TAKEAWAYS, but first, her story.

JULIE’S STORY

Julie is an award-winning gymnast from college days when she competed for the University of Oklahoma. Her team came in second place in the NCAA finals, which launched UO into the national spotlight.

In 2023, Julie began going to a licensed massage therapist to alleviate a medical condition. One aspect of this condition is that she occasionally becomes unconscious. The massage therapist, Ferris, was aware of her condition and there was a pre-arranged plan should it happen during the session.

In January of 2024, Julie became unconscious during a session. While she was unconscious, Ferris raped her. When she came to, he did not tell her he had raped her, of course.

By the time Julie realized she was pregnant, it was too late for an abortion due to strict Oklahoma laws. Ferris did not want her to keep the pregnancy and insisted she proceed with “Plan C”: an abortifacient medication. She refused but believes he spiked a drink with it, after which she hemorrhaged and almost lost the twins. The doctors suspected Plan C.

Ferris did not hide his irritation that the miscarriage hadn’t occurred, saying, “It would have been better if nature had taken care of itself.” While acknowledging paternity, he made it clear he wanted nothing to do with the twins and asked to not be put on the birth certificate.

TWINS BORN

In September of 2024, the twins were born. Julie did not put Ferris’ name on the birth certificate, as he had requested.

Julie remarried and her new husband became a wonderful father to the twins.

Ferris tried twice to get Julie to meet him at an isolated location, but she refused. She did not trust him, nor want anything to do with him. She suspects he would have killed her if she had met him, because he began overtly threatening to kill her.

He claimed he could get away with murdering her because he had “legal avenues” available to him [read: connections with judges]. He menacingly referenced high-profile murders in which two women were stabbed and buried in a freezer.

This led to Julie fearing for her children’s and her lives. She filed for and was granted a Temporary Restraining Order [TRO], which included the children.

THE TRICK

Oklahoma law requires an evidentiary hearing on the TRO within 14 days, so the hearing was scheduled for January 8, 2025. But, instead of hearing the case, Judge Sara Murphy Bonderant required Julie to file a motion to establish paternity, transmuting it into a custody case.

Judge Sara Murphy Bonderant

Judge Bonderant knew damn well violence is a separate issue that needs to be heard first, as she specializes in protection cases. This was a deliberate move to derail the rape case. A common ploy.

But it was black-and-white illegal. No grey area.

The law clearly states, “A court may not require the victim to seek legal sanctions against the defendant including, but not limited to, divorce, separation, paternity or criminal proceedings prior to hearing a petition for protective order.” Judges cannot delay victim protection by first requiring them to pursue other legal proceedings.

THE COVER-UP

Ferris promptly hired prominent family law attorneys and filed for custody and visitation.

The case was transferred to Judge James Siderias, another good ol’ boy soldier for the cause of empowering men after divorce.

Judge James Siderias

Judge Siderias could have simply heard the RO case and denied or dismissed it, but that would be difficult because of the strong evidence (DNA) of the crime. So he simply ignored it. He proceeded as if there had been no rape and Ferris was a father who had always wanted to be in the twins’ lives.

At a hearing in July, Ferris asked for a GAL to be appointed for the twins. This is absurd, considering the twins were only 10 months-old and could barely walk, much less talk to a lawyer. But GAL’s serve an important purpose: to give judges cover by spinning reports and recommendations against the mother and to the father.

Additionally, Ferris’ wife just happens to be a past president of a GAL agency, from which Siderias ordered one appointed. That makes it a legitimate conflict of interest.

But Julie was well-represented. She filed an opposition to the appointment of the GAL. Not surprisingly, Siderias completely ignored it. Another violation of law.

At an August hearing, Judge Siderias graciously allowed Julie to maintain custody but ordered supervised visitation for Ferris. A common first step in the Switch.

Julie kept insisting there should be a trial on the Restraining Order, which would establish the rape and hopefully keep the visits supervised. But Judge Siderias kept threatening her with contempt and jail.

In response to his threats, Julie requested a jury trial, which is allowed in Texas family courts. He backed off but still no RO hearing.

RELOCATION & ARMS RACE

Seeing the writing on the wall, Julie “temporarily relocated” across the border to Texas where her parents live. Parents with sole legal custody can move without permission from the other parent.

Thus began an arms race of sorts between Julie and Siderias:

DEC. 10: Julie notifies the court she has temporarily relocated to Texas.

DEC. 19: Judge Siderias grants sole custody to Ferris without notice or evidentiary hearing.

DEC. 22: Julie files in Oklahoma Supreme Court: Application to Assume Original Jurisdiction (asking the Court to intervene on an urgent matter); a Petition for Writ of Prohibition and Mandamus; and an Emergency Motion for Stay of Proceedings.

DEC. 23: Judge Siderias issues Writ of Habeas Corpus and Writ of Assistance, authorizing Texas law enforcement to “recover” the twins.

DEC. 25: Christmas day, Julie is granted a Temporary Restraining Order in Texas.

DEC. 26: Texas law enforcement comes with Siderias’ order in hand to take the twins. When Julie shows them the Texas RO, they decide not to take them.

Phew! One day—that’s as close as it gets!

But the arms race continues:

JAN. 5: Judge Siderias notifies Julie the final RO hearing will be the next day and says she can’t appear remotely. Julie was not given time to prepare and knew if she appeared in person, he would take the twins.

JAN 6: Judge Siderias dismisses the Restraining Order on the grounds that Julie failed to appear at the hearing. She is appealing.

JAN 27: Oral arguments will be heard before the Oklahoma Supreme Court. Stay tuned for the outcome!

TAKEAWAYS

This case demonstrates how DNA is king—when it’s the man’s that is. DNA supposedly makes a man a “father” in Family Court. He will be given custody, regardless of whether he is violent, or has ever done any parenting. Even of toddlers, like the twins in this case.

Even of nursing infants. Babies are being ripped from mama’s breast due to men’s supposed “right” to a child with their DNA. That is not what nature intended, nor is it in children’s, mothers’, or society’s best interests. [More on that in an upcoming column.]

An important takeaway is how easily a Temporary Restraining Order can be dismissed or ignored and then transmuted into a custody battle. This is a common ploy in service of covering up men’s abuse in order to switch custody to them.

Another takeaway is that judges can blatantly violate so many laws and policies in service of switching custody, even when the mother has good attorneys who point them out and object. Judges snarkily tell mothers to take it to the Appellate Court, knowing the worst that could happen is a slap on the hand.

Even when cases are overturned in appellate courts, they are usually just remanded back to the same trial court/judge—where judges do the same thing in a more clever way. Most mothers do not have the wherewithal or money to appeal anyway, so there is no effective way to hold judges accountable. [See: Down the Transparency & Accountability Rabbit Hole.]

One interesting factor in this case is the wife getting on board with taking kids from the mother. It begs the question, why would a woman want to raise kids who are the product of her husband’s rape?

Educated guesses: it enables them both to use custody to silence Julie about the rape. Or maybe she wants to mother the twins herself—for emotional reasons. Or maybe, just maybe, she’s afraid if she doesn’t go along with it or divorces him, he will be empowered to take her children (if she has any).

Which speaks to the throughline in all Custody Crisis cases: mothers do not have the power to keep or protect our children, thanks to Family Court judges having the power to take and endanger them.

SRY, the mammalian Y-chromosomal testis-determining gene, induces male sex determination. Recent studies in mice reveal that the major role of SRY is to achieve sufficient expression of the related gene Sox9, in order to induce Sertoli cell differentiation, which in turn drives testis formation. Here, we discuss the cascade of events triggered by SRY and the mechanisms that reinforce the differentiation of the testes in males while actively inhibiting ovarian development. Introduction

The development of two sexes is observed in most animals and is essential for their survival and evolution. Disorders of sex development (DSDs; see Glossary, Box 1) are among the most common genetic diseases in humans and are often associated with genital ambiguity (Kronenberg and Williams, 2007). Because of its clinical and biological importance, identifying the mechanism of sex determination – the developmental decision to generate either testes or ovaries – continues to attract the attention of a broad range of researchers, including developmental biologists, biomedical scientists, evolutionary biologists and ecologists.

In mammals, two major breakthroughs have shaped our current understanding of sex determination. First, in 1959, two human DSDs, Turner syndrome (XO females) and Klinefelter syndrome (XXY males) were identified and reported (Ford et al., 1959; Jacobs and Strong, 1959), and these studies established that the Y chromosome carries a gene that determines maleness. It would take another 30 years before the second breakthrough was made: the discovery of SRY (sex-determining region on the chromosome Y, denoted Sry in species other than humans). The human SRY gene was identified by searching for conserved sequences among translocated Y chromosomal DNA from four XX male patients (Sinclair et al., 1990). The presence of a similar gene, Sry, on the mouse Y chromosome was consistent with this gene having a sex-determining function (Gubbay et al., 1990). The role of Sry as the switch gene for mammalian sex determination was confirmed in experiments in which XX mice were converted to males by the introduction of Sry (Koopman et al., 1991).

Sry and the molecular mechanisms of sex determination have continued to be studied intensely over the past 20 years. Unlike other developmental systems that are well conserved through evolution, sex determination is highly variable in the animal kingdom, and the genetic mechanisms involved in common laboratory model organisms, such as flies, nematode worms, chickens and frogs, bear little, if any, resemblance to those used in mammals. Indeed, Sry is found only in mammals, though not in all mammalian orders – monotremes (see Glossary, Box 1), for example, lack Sry. Most of our current understanding of Sry and

Box 1. Glossary

Cell-autonomous. Occurring within a cell, not involving signalling between cells. Chromatin immunoprecipitation (ChIP). A method used to identify the transcriptional targets of a given transaction factor by precipitating the transcription factor while it is bound to DNA, then characterizing the bound DNA. Coelomic epithelium. Layer of cells lining the body cavity of an embryo. Disorder of sex development (DSD). Any one of a spectrum of conditions where the development of internal or external sexual organs differs from `typical' male or female, or is not as expected given the sex chromosomes present. Eutherian mammals. A subclass of mammals that have a placenta. Genital ridges. Pair of thickened rows of coelomic epithelial cells either side of the midline in the trunk of an embryo that are the precursors of the gonads. Granulosa cells. The `nurse' cells in ovarian follicles that nurture germ cells. High-mobility group. A specific family of transcription factors that have structurally related DNA-binding domains ∼80 amino acids long. Leydig cells. Cells in the interstitium of testes that produce androgens. Mesonephros. Embryonic structure attached to each genital ridge, from which the male or female internal sexual ducts arise. Monotremes. A subclass of mammals, represented by platypus, that lay eggs instead of giving birth to live young. Nuclear localization signal. A short sequence of amino acids that allows proteins such as transcription factors to move from the cell cytoplasm into the cell nucleus. Ovotestis. A gonad containing both ovarian and testicular tissue. Paracrine signalling. Short-range chemical communication between cells. Pre-Sertoli cells. Cells in an XY genital ridge that have activated Sry and Sox9 expression, but have not yet assembled into testis cord structures. Sertoli cells. Testicular cells that form testis cords and interact with and nurture germ cells. Testis cord. The precursors of the adult spermatogenic tubules, composed of germ cells enclosed by a layer of Sertoli cells. Theca cells. Cells in the outermost layer of the ovarian follicle that produce androgen as a source for neighbouring granulosa cells to convert to estrogens. WT1(+KTS)/WT1(–KTS). Isoforms of the Wilms tumour suppressor protein (WT1) that have three amino acids (lysine, threonine, serine: KTS) inserted or excluded, respectively. ZZ/ZW sex determining system. A system in which males have two identical sex chromosomes and females have two different sex chromosomes, in contrast to the situation with an XX/XY sex-determining system.

mammalian sex determination has come from studies in mice. In this primer, we summarize the results of these studies and discuss the insights they have provided into the molecular and cellular biology of mammalian testis development. Fig. 1.

Overview of sex determination in mice. Chronological flow of early mouse sex differentiation; the grey area indicates the period of sex determination. During mouse embryogenesis, bi-potential gonads (yellow) arise from the genital ridges by 10.5 dpc. In somatic cells of XY genital ridges, Sry expression (shown in dark blue beneath the schematic) starts at 10.5 dpc, reaches a peak at 11.5 dpc and then wanes by 12.5 dpc. A few hours later, Sox9 expression (shown in light blue beneath the schematic) is upregulated to induce differentiation of Sertoli cells. Sox9 expression peaks at 11.5-12.5 dpc, continues to be expressed postnatally and is supported by several positive-feedback loops (including FGF9, prostaglandin D2 and SOX9 itself), and SOX9 subsequently activates many male-specific genes, including Amh. At 12.5 dpc, testis cords have formed, and morphological differences between testis (blue) and ovary (pink) are evident. In the absence of SRY, genes such as Wnt4, Rspo1 and Foxl2 are expressed in a female-specific manner and induce ovarian development, as characterized by the expression of follistatin and many other ovary-specific genes. Abbreviations: Amh, anti-Müllerian hormone; dpc, days post coitum; FGF9, fibroblast growth factor 9; FOXL2, forkhead box L2; PGD2, prostaglandin D2; RSPO1, R-spondin 1; SOX9, SRY box containing gene 9; SRY, sex-determining region on the chromosome Y; WNT4, wingless-type MMTV integration site family, member 4.

An overview of the mammalian sex determination pathway

The most detailed studies of mammalian sexual determination have been carried out using mice as a model (Fig. 1). In mice, the gonadal primordia, which are called the genital ridges (see Glossary, Box 1) arise at 10.0 days post coitum (dpc). At this stage, there are no morphological or functional differences between male and female genital ridges, and both structures contain precursor cells that have the ability to differentiate into Sertoli cells (which support germ cells in the testis, see Glossary, Box 1) or granulosa cells (which have a cognate role in the ovary, see Glossary, Box 1).

Sex-specific gonadal development is triggered by Sry expression in somatic gonadal cells of XY genital ridges at 10.0-10.5 dpc (Fig. 2A). SRY activity upregulates Sox9 (SRY box containing gene 9) transcription in Sertoli cell precursors, which in turn upregulates other genes involved in the differentiation of Sertoli cells. Logically, SRY activity must also directly or indirectly suppress the female sex-determining pathway, which would otherwise continue to be active, as it is in XX genital ridges. Differentiating Sertoli cells then assemble into testis cords (tubular structures that contain the germ cells; see Glossary, Box 1) (Fig. 2). The Sertoli cells then stimulate the sex-specific development of germ cells, androgen-producing Leydig cells (see Glossary, Box 1), testis vascular cells and other interstitial (i.e. non-cord) cell types. The formation of testes is the hallmark of male sex determination.

By contrast, in the absence of Sry in XX gonads, genes such as Wnt4 (wingless-type MMTV integration site family, member 4) and Foxl2 (forkhead box L2) start to be expressed in a female-specific manner at 11.5-12.5 dpc, and upregulate other downstream female genes, such as follistatin. The female-specific programme of gene expression leads to the differentiation of granulosa cells and theca cells (see Glossary, Box 1), the production of oocytes, and the formation of ovarian follicles (Fig. 1). These events also occur in XY gonads that lack SRY function, supporting the key role for SRY in both activating the testis-determining pathway and suppressing the ovarian-determining pathway.

SRY structure and function

SRY is the founding member of the SOX (SRY-related HMG box) family of transcription factors. The SOX family is found throughout the animal kingdom, and comprises 20 members in mice and humans. SOX proteins have diverse roles in embryogenesis and in the development of many organs, typically acting as cell differentiation switches (reviewed by Bowles et al., 2000). SRY, like other SOX transcription factors, is characterized by a high mobility group (HMG; see Glossary, Box 1) DNA-binding domain (Fig. 3A). This domain binds to the sequence (A/T)ACAA(T/A) in the minor groove of DNA, inducing a 60-85° bend (Harley and Goodfellow, 1994) (Fig. 3B). Biochemical analysis of mutant human SRY protein from XY females has revealed that both DNA-binding and -bending are essential for SRY function. Furthermore, most human XY females have mutations in the HMG domain, reflecting the importance of this domain for the function of SRY (reviewed by Harley and Goodfellow, 1994). Fig. 2.

Chronological sequence of SRY and SOX9 expression during sex determination and early testis development in mice. (A) At 11.0 dpc, SRY (sex-determining region on the chromosome Y) protein is expressed initially in a group of somatic cells (green) in the centre of the genital ridge (indicated by a broken line). The domain of SRY-expressing cells then expands to occupy the entire length of the genital ridge; these cells are referred to as supporting cell precursors. (B) By 12.0 dpc, SOX9 (SRY box containing gene 9) expression is activated in these same cells, now referred to as pre-Sertoli cells. The SOX9-expressing cells assemble into testis cords by 12.5 dpc and are referred to Sertoli cells. SOX9 continues to be expressed in Sertoli cells at 13.5 dpc and beyond. Proteins were visualized by immunofluorescence using antibodies to SRY and SOX9. Images are courtesy of Dr Dagmar Wilhelm (The University of Queensland, Brisbane, Australia).

In contrast to the HMG domain, the remaining parts of SRY are poorly conserved between species, and no additional conserved functional domains have been identified (Fig. 3A). For example, in mice, only two amino acids make up the N-terminal region that usually comprises 30-60 amino acids in other species (Gubbay et al., 1990). In the C-terminal region of mouse SRY, a long glutamine (Q)-rich domain is present that is not found in other mammalian species but that might act as a transcriptional activation domain (Dubin and Ostrer, 1994). Sry transgene constructs that lack this domain fail to cause male development (Bowles et al., 1999), although it is not known whether this failure reflects a reduced stability of the truncated protein. XX transgenic mice that express human or goat SRY develop as males (Lovell-Badge et al., 2002; Pannetier et al., 2006), suggesting that the non-HMG-domain regions of SRY either are conserved in function but not in sequence, or have no function. In support of the former possibility, the human SRY protein has to be of full length to show normal DNA-binding ability in vitro (Sanchez-Moreno et al., 2008).

SRY protein also carries two nuclear localization signals (NLSs; see Glossary, Box 1) and target sites for acetylation and phosphorylation (Fig. 3A). The NLSs lie at each end of the HMG domain and are conserved between mouce and human (Sudbeck and Scherer, 1997); these bind calmodulin (a calcium-binding protein) and importin β (a nuclear import protein), respectively (Harley et al., 1996; Forwood et al., 2001; Sim et al., 2005) (Fig. 3A). Mutations in either NLS can cause human XY sex reversal, indicating that they are not functionally redundant (Battiloro et al., 1997; Veitia et al., 1997; Harley et al., 2003; Sim et al., 2005). Human SRY is acetylated at a single lysine residue that is well-conserved between species (Fig. 3A); acetylation enhances the nuclear localization of SRY by facilitating its interaction with importin β (Thevenet et al., 2004). Furthermore, human SRY is phosphorylated by cAMP-dependent protein kinase (PKA) on serine residues (S31-S33) located in the N-terminal part of the protein. This PKA-dependent phosphorylation of SRY increases its DNA-binding ability and its subsequent transcriptional activity, and is conserved across primates (Desclozeaux et al., 1998). Other possible phosphorylation residues (serine or threonine) are conserved in the N-terminal domain of SRY in all eutherian mammals (see Glossary, Box 1), except rodents, but the precise function of these residues has not been elucidated.

A number of proteins, including KRABO (kruppel-associated box domain only) (Oh et al., 2005; Peng et al., 2009), WT1 (Wilms tumour 1) (Matsuzawa-Watanabe et al., 2003), SIP1 (SRY-interacting protein 1) (Poulat et al., 1997) and PARP1 [Poly (ADP-ribose) polymerase] (Li et al., 2006) have been shown to interact with mouse and human SRY (Fig. 3A). However, most studies of these protein-protein interactions to date have been based on in vitro systems, and so their physiological significance is as yet unclear.

In summary, our understanding of the molecular mode of action of SRY remains rudimentary. Available evidence points to it having a role as a transcription factor that enters the nucleus, binds to DNA and then upregulates the expression of Sox9 (see below), but detailed structure-function relationships and how SRY functions in different mammalian species, despite its high sequence divergence, remain to be determined.

Sry expression and its regulation

Most data on of the regulation of Sry have been obtained from studies in mice, a species in which the expression of Sry in gonads is tightly regulated in both space and time. In the mouse embryo, Sry expression starts at 10.5 dpc in somatic cells of XY genital ridges, reaches a peak at 11.5 dpc and wanes by 12.5 dpc (Koopman et al., 1990; Hacker et al., 1995; Jeske et al., 1995; Bullejos and Koopman, 2001; Wilhelm et al., 2005) (Fig. 1, Fig. 2A). Its expression is associated with the differentiation of Sertoli cells in the testis but, clearly, continued Sry expression in mice is not needed to maintain the Sertoli cell phenotype.

In all other species studied, Sry expression in the gonads is maintained rather than transient, for reasons that are not clear. Furthermore, in some species, such as humans and wallabies, Sry expression is not limited to the gonads, and is instead expressed in many tissues during foetal development (Clepet et al., 1993; Harry et al., 1995). In these species, the function of SRY beyond its role in testis development has not been determined. Fig. 3.

SRY protein structure and function. (A) A comparison of SRY (sex-determining region on the chromosome Y) protein structure among five mammalian species: dunnart (Sminthopsis macroura, a marsupial), horse (Equus caballus), chimpanzee (Pan trglodytes), human (Homo sapiens) and mouse (Mus musculus). The HMG (high-mobility group) domain is shown in yellow. Numbers indicate the percentage of amino acids identical to human SRY. The locations of post-translational modification sites [nuclear localization signals (NLSs), phosphorylation sites, acetylation sites] and protein-protein interaction domains are indicated. Mouse SRY has a unique glutamine-rich domain, shown in purple. Between the HMG and glutamine-rich domains, mouse SRY has a `bridge' domain of unknown function, indicated in pink. Kruppel-associated box domain only and SRY-interacting protein 1 interacting sites are indicated (KRABO and SIp1). (B) SRY protein binding to DNA. The double-helix structure of DNA contains two different grooves, major and minor. The HMG domain of SRY binds to the sequence motif (A/T)ACAA(T/A) in the minor groove of DNA, bending double-stranded DNA at 60-85°.

One of the unique characteristics of mouse Sry expression is its peculiar spatio-temporal wave-like pattern: Sry expression is initiated in the centre of the genital ridge before extending to the whole length of the gonad over a period of several hours (Fig. 2A) (Bullejos and Koopman, 2001; Wilhelm et al., 2005). Thus, not all parts of the genital ridge are exposed to Sry transcripts, or protein, at the same time. The transient and dynamic expression of Sry in mice has highlighted the concept that Sry functions within a critical window of time in individual somatic cells of the developing gonad. This concept was suggested after observations of the phenomenon known as B6-YDOM sex reversal, which arises when specific variants of the Y chromosome from the mouse species Mus domesticus (YDOM) are crossed onto the genetic background of the C57BL/6J (B6) inbred mouse strain. Repeated crossing to B6 mice leads to a variety of phenotypes, ranging from delayed testicular development to the development of ovotestes (see Glossary, Box 1) or ovaries (Eicher et al., 1982). Curiously, when ovotestes develop, they tend to have a testicular structure in the centre, flanked by ovarian regions (Eicher et al., 1982). Detailed in situ hybridization studies have demonstrated that a delay in initiating the expression of Sry underlies B6-YDOM sex reversal: the peak level of Sry expression in XY B6 Ypos gonads is delayed by up to 10 hours (Bullejos and Koopman, 2005). Thus, a critical window of time during which Sry can direct Sertoli cell development appears to close while the Sry expression wave is still confined to the central region of these XY gonads (Fig. 4A).

The existence of a narrow and crucial time window for the expression and function of Sry has been confirmed in transgenic mice that carry a SRY gene driven by the heat shock protein 70.3 (Hsp70.3) promoter, which allows for the experimental induction of Sry at various time points. In this system, a 6-hour delay of Sry induction results in a failure to initiate the testis development pathway (Hiramatsu et al., 2009). The limits of this window may be dictated by the need to pre-empt the pathway of ovarian granulosa cell development that occurs in the absence of Sry, or by the availability of partner proteins required for SRY protein to activate Sox9.

In contrast to the timing of Sry expression, the initiation of which is particularly important, the duration of Sry expression appears to be immaterial, as it varies between species. For example, in humans and goats, Sry gene expression persists well beyond sex determination and is observed even after birth (Hanley et al., 2000; Pannetier et al., 2006). Taken together, the crucial factor that determines the ability of SRY to induce Sertoli cell differentiation appears to be whether or not it is able to exceed a required threshold level of expression in any precursor cell within a given window of opportunity (Fig. 4A).

In addition to the threshold of Sry expression being required for Sertoli cell differentiation, there is another threshold to consider: the number of Sertoli cells required for proper testicular development. In experiments in which chimaeras were generated by combining XX and XY early mouse embryos, gonads containing various proportions of XY cells were produced. When 35-40% of somatic cells were XY, testes were formed, but when fewer than 10% were XY, ovaries were formed (Burgoyne et al., 1988) (Fig. 4B). Intermediate proportions of XY cells resulted in ovotestes.

A further observation to arise from these studies was that most, but not all, Sertoli cells in XX↔XY chimaeras were XY (Palmer and Burgoyne, 1991). These findings suggested that SRY expression normally drives Sertoli cell differentiation; however, it was also clear that SRY expression might not be an absolute requirement, and that XX cells could be recruited to the Sertoli cell population, perhaps by paracrine signalling (see Glossary, Box 1). More recently, studies of normal mouse testicular development using SOX9 and SRY antibodies have revealed the existence of pre-Sertoli cells (see Glossary, Box 1) that express SOX9 without having first expressed SRY (Wilhelm et al., 2005). Moreover, in in vitro cultures that contain a mix of XX genital ridge cells that constitutively express a fluorescent marker and XY wild-type genital ridge cells, it has been shown that when the XY cells are in contact with the XX cells, the XX cells are induced to express Sox9, confirming the existence of a paracrine recruitment mechanism (Wilhelm et al., 2005). This phenomenon can be artificially induced by prostaglandin D2 (PGD2), and inhibited by a chemical blocker of the PGD2 receptor, implicating PGD2 in this paracrine recruitment mechanism (Wilhelm et al., 2005). Accordingly, Pgds (prostaglandin D synthase)-knockout mice show decreased Sox9 expression in male gonads (Moniot et al., 2009). This mechanism is likely to provide a backup system to ensure and to reinforce male pathway activation by SRY. Fig. 4.

Two thresholds important for mouse sex determination. (A) Sry expression levels must exceed a certain threshold (blue) within a narrow time window (grey) in individual somatic gonadal cells of developing mouse gonads in order to induce Sertoli cell differentiation (curve A). If the level of Sry expression does not reach the threshold, as in WT1(+KTS)-null mice (curve B), or is delayed and misses the critical window, as in YDOM sex reversal (curve C), somatic gonadal cells fail to differentiate into Sertoli cells. (B) The number of supporting cell precursor cells that differentiate as pre-Sertoli cells must also reach a certain threshold level in order to induce testis formation (blue). In XX-XY mouse chimaera experiments (Burgoyne et al., 1988; Palmer and Burgoyne, 1991; Patek et al., 1991), in which the proportions of XY and XX cells making up an embryo varies, the gonad fails to form a testis if the number of Sertoli cells is below a threshold, resulting in the development of an ovotestis (grey) or an ovary (red). Abbreviation: Sry, sex-determining region on the chromosome Y.

Table 1.

Genes implicated in regulating Sry expression

In spite of the importance of its correct temporal and spatial expression, the regulation of Sry is still poorly understood. Regions that flank Sry are remarkably poorly conserved between mammalian species, hampering efforts to find potentially important regulatory elements. Although sequence analysis has revealed four intervals of relatively high DNA sequence conservation upstream of SRY among human, bovine, pig and goat genomes (Ross et al., 2008), the physiological significance of these sequences has not been determined. Transgenic mouse assays (in which critical regulatory regions are pinpointed by sequential deletion analysis) have so far not been useful for identifying a gonadal enhancer of Sry.

Despite these complications, several proteins have been implicated in regulating Sry expression (Table 1). Analyses of gene knockout mouse models have shown that the absence of these proteins leads to reduced levels of Sry expression, and results in XY sex reversal. In most cases, it is not clear whether the loss of these factors reduces the level of Sry expressed per cell or the overall number of cells that express Sry. How loss of their function leads to reduced Sry is also unclear for most of these proteins. For example, FOG2 (friend of GATA2; now known as ZFPM1 – Mouse Genome Informatics) is known to be involved in the repression rather than in the activation of several GATA-dependent target genes, such as anti-Müllerian hormone (Amh) and inhibin α (Robert et al., 2002). CBX2 (chromobox homologue 2), MAP3K4 (mitogen-activated protein kinase kinase kinase 4) and insulin receptors are not transcription factors, and so how they might influence Sry regulation remains to be determined. A recent bioinformatics study identified a region of mouse chromosome 1 between 33 and 49 cM that controls the expression of Sry, but none of the above genes is located within this region (Munger et al., 2009).

Among the molecules described above, much attention has focused on WT1 as a potential regulator of Sry. When WT1(+KTS) (see Glossary, Box 1) is reduced in humans, XY sex reversal occurs, accompanying a condition known as Frasier syndrome (Barbaux et al., 1997). Studies in mice show that WT1(+KTS) plays a cell-autonomous (see Glossary, Box 1) role in regulating Sry expression in individual cells of the Sertoli cell lineage in vivo (Bradford et al., 2009b), but it is not clear whether Sry is a direct or indirect transcriptional target of WT1. In in vitro systems, WT1(+KTS) activates the promoter of mouse but not of human Sry (Shimamura et al., 1997; Hossain and Saunders, 2001; Miyamoto et al., 2008); moreover, WT1(+KTS) preferentially binds to unspliced pre-mRNAs, promoting gene expression by mRNA processing (Morrison et al., 2008). Thus, the mechanism of Sry regulation by WT1(+KTS) is unclear and requires further study.

In summary, the precise regulation of both the levels and onset of Sry expression is important for Sertoli cell differentiation and hence for testis development. The mechanistic details of how this regulation is achieved, however, remain unknown. Mechanism of SRY action

After the discovery of Sry, attention turned to the issue of whether it might directly upregulate the male sex-determining pathway, or repress a repressor of that pathway (see Box 2). Much of this work focused on the relationship between Sry and Sox9, another important and early-acting gene that is expressed in Sertoli cells. In particular, studies have aimed to address whether SRY might regulate Sox9 expression directly or indirectly, and whether Sox9 might be just one of many targets of SRY. Sox9: a major SRY target

Sox9, which encodes another member of the SOX transcription factor family, is expressed in several developing vertebrate organ systems, including the skeleton, heart, kidneys and brain (Wright et al., 1995). In XY mouse gonads, Sox9 expression is upregulated in pre-Sertoli cells immediately after the onset of Sry gene expression, and mimics the wave-like pattern of Sry expression (Kent et al., 1996; Morais da Silva et al., 1996; Sekido et al., 2004; Bullejos and Koopman, 2005; Wilhelm et al., 2005). However, unlike Sry in mice, Sox9 expression persists in the gonad beyond 12.5 dpc (Fig. 2B) (Kent et al., 1996; Morais da Silva et al., 1996), suggesting that it is able to sustain its own expression once initiated (Fig. 1), and that its continued expression might be linked to the maintenance of the Sertoli cell phenotype (DiNapoli and Capel, 2008).

The importance of SOX9 for sex determination was revealed when heterozygous human SOX9 mutations were found to be associated with a skeletal deformity syndrome: campomelic dysplasia (CD) (Foster et al., 1994; Wagner et al., 1994). In 75% of XY individuals with CD, partial or complete male-to-female sex reversal occurs, indicating that SOX9 is necessary for testis determination in humans (Mansour et al., 1995). In addition, a duplication of SOX9 had previously been identified in a mosaic XX sex-reversed individual (Huang et al., 1999). These observations indicated that SOX9 is sufficient and necessary for testis determination, a conclusion confirmed by the sex reversal phenotype of XY Sox9-null (Chaboissier et al., 2004; Barrionuevo et al., 2006) and XX Sox9-overexpressing mice (Bishop et al., 2000; Vidal et al., 2001). Consistent with the role of SOX9 as a testis-determining factor, several genes that have a crucial role in testicular development, such as Amh and Pgds, have been identified as direct targets of SOX9 (De Santa Barbara et al., 1998; Wilhelm et al., 2007).

Unlike Sry, Sox9 is conserved among non-mammalian vertebrate species. In addition, Sox9 is linked with sexual dimorphism and with gonadal development in species such as the chicken, which has a ZZ/ZW sex-determining system (see Glossary, Box 1) (Schmid et al., 1989), and red-eared slider turtles and alligators,

Box 2. The quest to find the molecular function of SRY Despite being long suspected, it took over a decade to prove that SRY (sex-determining region on the chromosome Y) regulates Sox9 (SRY box containing gene 9) directly. Why did it take so long? Sry has some peculiar features that make it particularly difficult to work with. The non-HMG domain sequence of mouse Sry gene does not have obvious functional domains and is poorly conserved between species. As a result, it was not known whether SRY acts as a transcriptional activator or a repressor, or even as an architectural factor that acts by changing DNA structure. The fact that SRY binds to a short (seven-base) target sequence that occurs frequently in the genome made it difficult to identify potential target genes bioinformatically. Furthermore, a lack of suitable cell lines and antibodies hampered molecular approaches. Useful and specific antibodies to SRY now exist, although cell lines remain a problem, as cells typically lose SRY expression after a few passages in culture. Nor has it been easy to work backwards from Sox9 to find out what regulates its expression, or whether SRY is involved. Translocations and deletions affecting Sox9 function indicate that regulatory elements exist 1 Mb or more upstream of this gene in mice and humans (Bishop et al., 2000; Pfeifer et al., 1999). Painstaking deletion analysis in transgenic Sox9 reporter mice finally revealed the gonadal-specific enhancer of Sox9, called testis-specific enhancer of Sox9 core (TESCO), on which SRY acts directly (Sekido and Lovell-Badge, 2008). Even now it is not clear whether TESCO is the only element important for Sox9 regulation during sex determination.

which have a temperature-dependent sex-determining system (Spotila et al., 1998; Western et al., 1999). Therefore, the role of SOX9 in sex determination is considered to be ancestral and pivotal among vertebrates. Furthermore, because the phenotype of Sox9 overexpression in mouse XX gonads recapitulates that of Sry overexpression, Sox9 is thought to be the only gene that is required downstream of Sry to activate the remainder of the testis-determining programme.

How does SRY upregulate Sox9 expression? A recent analysis using transgenic reporter assays and in vivo chromatin immunoprecipitation (ChIP, see Glossary, Box 1) assays identified a gonad-specific enhancer of mouse Sox9, called TESCO (for testis-specific enhancer of Sox9 core) (Sekido and Lovell-Badge, 2008). TESCO is a 1.4 kb sequence that is located 11-13 kb upstream of the Sox9 transcription start site and is highly conserved in rat, dog and human genomes. SRY and SF1 (steroidogenic factor 1), an orphan nuclear receptor that regulates many genes involved in the differentiation of gonadal and adrenal cells, were found to cooperatively upregulate mouse Sox9 by directly binding to TESCO (Sekido and Lovell-Badge, 2008) (Fig. 5), providing the first evidence that SRY acts as a transcriptional activator in vivo.

The discovery of TESCO also clarified another significant mechanism of Sox9 regulation: an auto-regulatory positive-feedback loop (Fig. 5). SOX9 itself binds to TESCO with SF1 to stimulate its continued expression (Sekido and Lovell-Badge, 2008). This positive feedback loop is important not only to maintain Sox9 expression after Sry subsides in mice, but also to ensure that the SRY signal is captured and amplified in each developing Sertoli cell. A positive-feedback loop is also observed between fibroblast growth factor 9 (FGF9) and SOX9 (Kim et al., 2006). Fgf9 has not been proven to be a target of SOX9, but is known to be necessary for the maintenance of Sox9 expression. Fgf9-null mice or mice lacking FGFR2, the main receptor for FGF9, show XY sex reversal (Colvin et al., 2001; Kim et al., 2007), attesting to the importance of FGF9 in the testis-determining pathway. Furthermore, a centre-to-pole diffusion of FGF9 appears to be essential for proper testicular development in the polar extremities of male mouse gonads, because polar fragments of mouse foetal XY genital ridges cultured separately from central fragments did not maintain Sox9 expression or form testis cords (Hiramatsu et al., 2010). Fig. 5.

Cellular mechanism of SRY function. A schematic of the cellular mechanisms of SRY action. In the cytoplasm, SRY is bound by calmodulin (CaM) and importin β (Impβ), which recognize the N- and C-terminal nuclear localization signals (NLSs) on SRY, respectively, and recruit it to enter the nucleus. At 10.5 dpc, SRY and steroidogenic factor 1 (SF1) bind directly to specific sites (`TESCO', testis-specific enhancer of Sox9 core) that lie within the gonadal specific enhancer of Sox9 (indicated by the coloured regions on the DNA) and upregulate Sox9 expression cooperatively. At 11.5 dpc, after initiation of Sox9 expression, an auto-regulation system operates in which SOX9 also binds directly to TESCO with SF1 to prolong and amplify Sox9 expression. Abbreviations: SOX9, SRY box containing gene 9; SRY, sex-determining region on the chromosome Y.

Thus, at least three mechanisms are used to ensure the continued expression of Sox9 and to recruit gonadal somatic cells to the Sox9-positive Sertoli cell population: cell-autonomous Sox9

Box 3. Sry and sex-specific brain function In mice, Sry (sex-determining region on the chromosome Y) is not only expressed in developing gonads, but also in the brain. It is tempting to hypothesise that SRY has some direct role in brain sex determination. So far, a few genes encoding proteins such as monoamine oxidase A (MAO-A) and tyrosine hydroxylase (TH), have been identified as potential targets of SRY in the brain (Milsted et al., 2004; Dewing et al., 2006; Wu et al., 2009). However, the physiological significance of these pathways and the regulatory mechanisms of Sry in the brain have yet to be elucidated. Because so little is known about sex-specific brain differentiation, and because the topic itself is fraught with controversy, it is a challenging task to prove that SRY has a direct role.

autoregulation, PGD2-mediated signalling and FGF9-mediated signalling from Sertoli cells. These regulatory loops induce the activation of other downstream male pathway events, such as Amh expression, cell proliferation in the coelomic epithelium (see Glossary, Box 1), cell migration from the mesonephros (see Glossary, Box 1) and testis-specific glycogenesis (Martineau et al., 1997; Capel et al., 1999; Schmahl et al., 2000; Schepers et al., 2003; Matoba et al., 2005; Matoba et al., 2008). Additional SRY targets in gonads

Other than Sox9, few SRY target molecules in gonads have been reported. A recent in vivo ChIP study showed that the cerebellin 4 precursor gene (Cbln4) is a direct target of mouse SRY (Bradford et al., 2009a). Cbln4 encodes a transmembrane protein and is expressed in a male-specific manner. However, the function of Cbln4 product in testicular development is not known.

Human and mouse SRY have also been found to interact with β-catenin and to repress β-catenin-mediated TCF-dependent gene activation (Bernard et al., 2008; Tamashiro et al., 2008; Lau and Li, 2009). β-Catenin is the downstream effector molecule of WNT4/R-sponsin 1 (RSPO1) signalling and appears to be essential for initiating the development of the female gonad (Maatouk et al., 2008). It is attractive to speculate that, in order to activate the male pathway efficiently, SRY suppresses the function of the key female molecule β-catenin. However, evidence that SRY affects β-catenin function is based solely on in vitro data and its physiological significance in vivo has not yet been demonstrated.

In summary, the only clear direct target of SRY during testis determination is Sox9, and so understanding the role of SRY in engaging the testis-determining pathway becomes an issue of studying the molecular roles of SOX9. Interestingly, in mice, Sry is also expressed in the brain, where other potential targets of its protein have been identified (see Box 3); these targets are brain specific and so are not relevant to gonadal development. Conclusion

Despite its dramatic biological role, Sry is a fragile and partly debilitated gene. The structure and regulatory sequences of Sry may have been degraded because of its location on the rapidly degrading Y chromosome (see Box 4). To respond to the weak Sry expression signal and to establish the male pathway efficiently, Sox9, apparently the only meaningful target of SRY, has acquired support mechanisms for its own regulation, in the form of cell-autonomous and intercellular signalling-based positive-feedback loops. Thus, SRY provides the trigger for male sex determination,

Box 4. Y-chromosome evolution and Sry Sry (sex-determining region on the chromosome Y) determines the sexual fate of the organism, but also the fate of the Y chromosome itself. Gene-mapping analysis suggests that the X and Y chromosomes evolved from a pair of identical chromosomes (Graves, 2006) that began to differentiate when one copy of Sox3 (SRY box containing gene 3) acquired a new function in male sex determination. The chromosome carrying this new gene, Sry, became the Y chromosome. The ancestral Sox3, the role of which is largely restricted to brain development, resides on what has become the X chromosome. Having established a new Y chromosome, subsequent selection favoured restricted recombination with the new X, so that Y genes would stay on the Y chromosome. Because recombination is part of the mechanism used by cells to proofread and repair genes, genes in the non-recombining region of the Y chromosome tend to become lost and/or degraded. As a result, the human Y chromosome has shrunk to ∼60 Mb and contains only 50 functional genes, whereas the human X chromosome is ∼165 Mb and carries ∼1000 genes (Graves, 2002; Graves, 2006; Wallis et al., 2008). Erosion of the Y chromosome is reflected in the accumulation of Sry mutations, explaining the high level of sequence divergence between mammalian species and perhaps accounting for its relatively low expression levels in mice. Not surprisingly, the use of Sry as a testis-determining trigger seems to have been lost altogether in some species, such as the mole voles Ellobius lutescens and E. tancrei, and the Japanese spinous country rats Tokudaia osimensis osimensis and T. osimensis (Just et al., 1995; Sutou et al., 2001). The sex chromosomes in these species are XO or XX; no Y chromosome or any trace of Sry are present, suggesting the existence of a completely new sex-determining system.

but it is actually SOX9, and not SRY, that is the key element that orchestrates and stabilizes Sertoli cell differentiation to lock in the testis-determining program. At the same time, SOX9 provides a means of blocking the pathway of gene activity that leads to the differentiation of ovarian cells, but the mechanism by which it does so remains unclear.

Intensive studies spanning more than 20 years since the discovery of Sry have identified several genes important for sex determination and gonadal development, and yet 30-40% of human XY DSD cases still remain undiagnosed. Given the importance of correct Sry regulation, as demonstrated in experimental studies, it may be that regulatory mutations in the unidentified enhancer sequences of SRY may be an important contributing factor to human DSDs. Further study is required to test this possibility. Other fundamental questions about this gene and its protein still remain unanswered: what are precise molecular mechanisms of Sry regulation; what are the functions of the non HMG-domain regions of the protein; and what is the physiological significance of its protein interactions? Recent technical advances, including bioinformatic analysis and the generation of genetically modified mice, will help to answer the remaining questions surrounding the process of mammalian sex determination, and may provide valuable information for the diagnosis and management of human DSDs.

Acknowledgements

Inmate photo of Mia Bailey released following her sentencing. (Photo: Utah Department of Corrections)

WASHINGTON CITY, Utah (KUTV) — Mia Bailey said she decided to kill her parents after her mother interfered with a gender transition surgery.

According to newly acquired interrogation video from Washington City police in June of 2024, then-28-year-old Bailey detailed what led her to kill both her parents, how she did it, and the flee from police that followed.

Bailey cited years of turmoil with her parents.

"I told them I was going to kill myself so many times," she said. "Mental health declining, that’s why I needed that surgery."

Bailey said she was dealing with an abusive family, was homeless, and had $20,000 in debt from hormone replacement therapy and other fees with transitioning.

She described that her one thing keeping her together was the plan for a gender affirming surgery but her mother called the hospital.

"She was trying to sabotage it. She always had boundary issues," Bailey said. "I had one thing going on, and she took that away from me. [...] She can't say sorry to save her life, apparently. And I gave her so many chances throughout my life."

Bailey said that led her to decide to kill her parents, saying, "Enough is enough, I'm taking someone with me".

"I went to my parents to do the deed. Kill them," she described. "It was spur-of-the-moment. I don’t regret it. I hate them. That was the last straw."

She said she went to their home with a gun bought from a pawn shop in town.

"I told myself to throw away that part of me," she described from entering her parents' home. "I ran in the door."

She said she shot about 12 rounds, including one round at her brother through a door. She said she didn’t think it would hit her brother, but "if it did, then so what?"

Bailey then recounted her flee from the police and searching for a final bullet to kill herself, laughing about running through yards and hiding from helicopters in the south St. George area. She also described ways she could have covered the scene, but felt it wouldn't have made a difference.

"I actually was going to plan on standing over the cliff," Bailey told investigators. She explained that if one of the police officers did not shoot her, the fall from the cliff would.

Bailey ended her confession by saying there needs to be more support for the LGBTQ community and that people should be able to transition with less interference.

She said that while she came across other people during her flee, she knew they were not her target.

"Enough dead people for the day, or for life, I should say," she said.

Bailey was charged with two 25-year life sentences in December of 2025. Bailey pleaded guilty to the killing of her parents in Washington City in November 2025, more than a year after her arrest. Her change of plea came with an amended set of charges of two counts of aggravated murder and one count of aggravated assault.

She does not think the money is worth the risks

Escort Kat Lee sells sex lessons to students for a discounted price

A former sex worker who claims to have slept with “one million men” for £140-an-hour now thinks prostitution should be banned - because it's lonely, dangerous and damaged her health.

Kat Lee from Manchester began working legally as an escort alongside her twin sister when she was a teenager - after a photographer lured them into the industry. She described herself as an 'outcall' escort, meaning she visits clients, rather than inviting them to her home or hotel room.

But after a 15-year career, Lee, 32, has decided to leave the industry to become a bartender and charity volunteer, and has issued a warning about how the stigma of her previous profession has damaged her work chances.

“I worked as an escort from when I was 18 until I was in my 30s, I must have seen over a million clients,” Lee said. “I was a teenager when I got into it. It started because of a photo shoot where me and my twin sister were asked to take off our tops and knickers for an adult magazine.

“Later, the photographer said we would be good in adult movies, being twins, and that led to escorting.”

While working as an escort, during which time she said she felt like Julia Roberts in Pretty Woman, Lee received various gifts including an Audi convertible and trips to Milan and Paris.

Kat Lee says there are "better ways to live" than escorting

But although she always took precautions regarding her safety, but was once caught out by a man who spiked her drink.

She said: “I’ve only been in one dangerous situation on the job - when a client spiked my drink and took the money back after I was paid. I thought I was going to die. I couldn’t breathe or anything. I had a driver to get me to jobs and I wouldn’t have got home without him.

“I never caught diseases from clients, but I feel a lot safer in my bar job with CCTV. I used to see four to five clients a day. You do get idiot clients who come in drunk.”

One of the most dangerous aspects of the job was Lee’s own drinking in an effort to gain confidence before meeting clients - which led to her being hospitalised to have her stomach pumped.

“If I turned down a client, the agency would fine me £50, so I started to find my own clients. It meant I would be waiting in hotel bars for my next job and I would drink to gain confidence before seeing a client,” she said. “That led to public disorder offences and ending up in the hospital to have my stomach pumped.”

Looking back on her long career in the sex work industry, Lee also recalled how lonely it was - because “women doing it would dislike me because men booked me more than them.”

And despite continuing to work on webcam to “stay in touch with regulars,” Lee does not believe she will return to escorting.

“It was something that I got into and didn’t mean to. I carried on working and then it became a habit,” she said. “You can’t really get a different job because you’re on Google and you already have the attention.”

Because of the stigma associated with the work, as well as the dangerous situations escorts can find themselves in, Lee thinks a ban would be a “good thing.”

“Some people turn to prostitution for drugs or a place to live. There’s no jobs or houses so they turn to prostitution to find money to leave home."

She said it's weird earning £7-an-hour in the bar when she used to make £140 as an escort. "You think ‘Oh my God, I could have worked one hour for £140 instead of many hours work at £7,” she said.

ABSTRACT

In most European countries, medical interventions including puberty blockers and cross-sex hormones are still the first-line treatment for gender dysphoria (GD) in adolescents. This paper presents a cumulative case for instead adopting non-medical interventions as the first-line intervention. These include awaiting further identity development, psychosocial support, and psychotherapy aimed at relieving gender-related distress, while respecting the adolescent’s gender identity. The cumulative case is built from the following considerations. First, there is a significant lack of knowledge of the natural history of GD. Second, the causes of the changed profile of patients referring to gender clinics, now relatively many more natal females with adolescent onset GD and co-occurring mental health problems than before 2010, are poorly understood. Third, there are clear indications that puberty blockers may impede adolescent identity development, rather than providing relief and facilitating reflection, as intended. Fourth, despite insufficient and inconsistent evidence on both harms and benefits of medical treatment of GD, most likely the harms and risks outweigh any potential benefits. Fifth and finally, non-medical interventions are not inherently unethical, but rather the least invasive potentially effective intervention. Together, these five considerations constitute a strong case against early medical intervention and in favour of non-medical interventions.

1. Introduction

In the 1990s, the Dutch gender clinic in Amsterdam started to medically intervene in minors with gender dysphoria (GD). Adolescents with persisting GD became eligible for cross-sex hormones (CSHs) from age 16 onwards, and soon after, puberty blockers (PBs) became available for 12 year-olds. In the early 2000s and thereafter, this so-called ‘Dutch approach’ spread through many Western countries and the medical treatment model became the standard.

Over the past few years, however, several European countries have changed course to a more cautious approach, emphasizing psycho-social and other non-medical interventions as the first-line treatment. The growing acknowledgement of the weakness of scientific evidence on the benefits and harms of PBs and CSHs (Cass Review, Citation2024; Miroshnychenko, Ibrahim, et al., Citation2025) has been instrumental to this change. However, many European countries continue to routinely offer early medical intervention as the first line of treatment to adolescents with GD.

Building on the fundamental medical ethical principles of beneficence and non-maleficence and the norm that, in principle, less invasive interventions ought to be prioritized, this article argues against early medical intervention in gender dysphoric youth as the first line of treatment, and in favour of non-medical interventions. These include psycho-social support, treatment of co-occurring mental health problems, and psychotherapy treatments aimed at reducing gender-related distress (while respecting adolescent’s identity). In order to build the moral case for these non-medical interventions, the next section will first briefly explain what GD is, what we know and do not know about its natural history, and outline the medical gender affirmative care model. Then a developmentally informed approach will be taken to investigate how adolescent identity development and GD are intertwined, and how both may be impacted by early medical intervention. The next section will evaluate the harm-benefit profile of PBs and CSHs. Subsequently, two dominant charges against non-medical intervention will be evaluated: that they would be ineffective and unethical. Finally, two alternative justifications for early medical intervention, each acknowledging the weakness of the evidence base, are critically evaluated. In the concluding discussion, the findings of the separate sections are integrated into a cumulative case in favour of non-medical interventions as the first-line treatment for GD in adolescents, while simultaneously being studied within the context of a rigorous research programme to evaluate their effectiveness.

2. Gender dysphoria and medical treatment

Informally, gender incongruence (GI) refers to a strongly felt incongruence between one’s experienced gender and one’s natal sex. GI is also a formal ICD-11 diagnosis. Gender dysphoria (GD) can be understood as GI that is accompanied by distress. In its colloquial meaning, GD refers to significant distress regarding one’s sexed body and the gender one lives in, whereas GD may also refer to the formal DSM-V-TR diagnosis GD.

An important distinction is between childhood onset and adolescent onset GD. The natural history of childhood onset GD, which emerges well before puberty, is poorly understood. Population-based prevalence and incidence data are absent. Among various clinic-referred samples of pre-pubescent children with the DSM diagnosis ‘Gender Identity Disorder’, the precursor of GD, more than half (Ristori & Steensma, Citation2016), or, more precisely, on average 67% (Zucker, Citation2018) of them, no longer were gender dysphoric at the time of follow-up some years after the onset of puberty. Most of these children turned out homosexual as adults, which is consistent with the fact that gender non-conforming behaviour in childhood is common for homosexual people. Gender clinicians widely assume that GD that persists until after the onset of puberty is unlikely to resolve (e.g., de Vries & Cohen-Kettenis, Citation2012, p. 306). However, this assumption is not supported by research (Cf. Byrne, Citation2024). In addition, clinical experience is biased in many ways, especially observer bias. Clinicians never saw those adolescents with childhood onset GD whose gender dysphoria resolved several years after the onset of puberty, but whose parents never brought them to the gender clinic. In other words, it is unknown which share of children would (sufficiently) outgrow their GD without receiving specialist gender care.

Adolescent onset GD refers to GD that emerged with or after the onset of puberty. Historically, adolescent onset GD has mainly been studied in natal males (Leibowitz & de Vries, Citation2016), but from roughly 2010 onwards, many more adolescent natal females started to present to gender clinics (Cf. Kaltiala-Heino et al., Citation2018; Taylor et al., Citation2024). Among them, mental health issues, psychiatric comorbidity, and neurodiversity are common, with the causes of the change in sex-ratio towards a preponderance of natal females still being poorly understood (Taylor et al., Citation2024). While the natural history of the ‘classic’ childhood onset GD is itself poorly understood, this is even more the case with adolescent onset GD in natal females (Kaltiala-Heino et al., Citation2018). Relevant follow-up studies elucidating the natural history are lacking and clinical experience, prone to bias anyway, is much shorter than for childhood onset GD.

Medical treatment according to the currently still dominant ‘gender affirming care’ model consists of several phases (Coleman et al., Citation2022). The guiding idea of this model is that adolescents should be affirmed in their gender identity. For prepubertal children, often already socially transitioned, no medical interventions apply. If GD persists after the first stages of puberty, a diagnostic phase is initiated, which may result in starting with PBs. In the Netherlands, if GD still persists after, approximately, age 15, CSHs can be considered, followed by mastectomy at age 16 (Federatie Medisch Specialisten, Citation2018), but ages depend on country and healthcare provider and are sometimes still lower; the Standards of Care from the World Professional Association of Transgender Health from 2022 even has no age limits at all for these interventions, see Coleman et al. (Citation2022). Genital surgery is generally reserved for age 18 and beyond. Psychiatric co-morbidity generally is no contra-indication, because this is seen as likely to be secondary to gender incongruence. Mental health issues may, however, be addressed prior or simultaneously to medical treatment when they complicate diagnostic assessment or treatment adherence.

3. Adolescent identity development, gender dysphoria and medicalization

Adolescence is a crucial period of identity exploration and formation, both in a global sense and with respect to more specific identity-related aspects and domains such as worldview, religion, occupation, friendship, and also gender (Kroger, Citation2017). Most adolescence studies in developmental psychology are based on a model that was introduced by James Marcia (Citation1966), and that was on its turn based on ideas of Erik Erikson. In essence Marcia developed a model of four statuses, defined by the presence or absence of exploration (trying out different roles, beliefs, ideologies) and the presence or absence of commitment (making personal investments in these roles, beliefs and ideologies) (Kroger, Citation2017). The four statuses are: identity diffusion (no exploration, no commitments), identity foreclosure (commitment without significant exploration), identity moratorium (ongoing exploration without commitment) and identity achievement (resolving the adolescent identity crisis by making a firm commitment after a period of thoughtful exploration).

Adolescent identity development has a fundamentally social nature, involving various interpersonal processes and the formation of relationships. Gender dysphoria both affects, and is affected by, identity development. The onset of pubertal physical development profoundly affects psychosexual development. For some individuals, developing secondary sex characteristics initiates or exacerbates their gender dysphoric feelings, which may prevent them from engaging in romantic experiences. For others, the development of their body and, for example, falling in love, turns out to be instrumental in the resolution of their GD (Steensma et al., Citation2011). Gender dysphoria may be (partly) constituted by feelings of not fitting in with the gender role attached to one’s natal sex, by being treated as a member of one’s natal sex, or related to other social aspects of gender. This may lead to social withdrawal (Galupo et al., Citation2020), thereby impeding normal identity development.

Given these complex relations between adolescent identity development and GD, it is hard to predict the impact of early medical intervention, i.e., puberty blockers and cross-sex hormones, on adolescent identity development. Regarding puberty blockers, on the one hand, it appears plausible that halting puberty may indeed give adolescents rest and peace of mind, facilitating identity exploration and formation. On the other hand, from the very beginning, gender clinicians have also expressed concerns: ‘[a]dolescents may consider this step [i.e., starting puberty suppression] a guarantee of sex reassignment, and it could make them therefore less rather than more inclined to engage in introspection' (Cohen-Kettenis & van Goozen, Citation1998, p. 248, emphasis added). In terms of Marcia’s identity status model, this can be rephrased as the concern that puberty suppression leads to identity foreclosure: gender dysphoric youth may fixate on a future life as another gender, without first going through an adequate process of (gender) identity exploration.

Although there is no definite evidence, the available empirical evidence suggests that puberty blockers may be more likely to impede rather than facilitate gender identity exploration and development. First of all, the percentage of adolescents that continue treatment with cross-sex hormones after puberty suppression is very high, more than 95% (e.g., Carmichael et al., Citation2021). Remember that our knowledge of the natural history of GD is insufficient, and therefore, it cannot be claimed that such extremely high percentage was to be expected because GD would most likely not resolve after the onset of puberty. If puberty suppression would indeed facilitate identity exploration and development, one would expect that as a result, at the very least somewhat more adolescents would decide not to opt for medical treatment as a way to deal with their dysphoria, or would even (sufficiently) outgrow their gender distress.

Second, there are plausible mechanisms that explain how puberty suppression may impede reflection and identity exploration. As already noted, pubertal development of the body is essential for psychosexual development, and therefore puberty suppression may withhold adolescents’ essential bodily and romantic experiences that otherwise could have been instrumental in resolving their GD. Relatedly, puberty is a crucial period for brain development caused by increased levels of sex hormones. There are some indications that puberty blockers may indeed have a negative impact on cognition (Baxendale, Citation2024).

Third, a Dutch empirical study indicates that the (vast) majority of patients regard puberty blockers as the first step of their medical transition, rather than as interventions providing ‘time to think’ about whether to medically transition (Vrouenraets et al., Citation2022).

Finally, an early Dutch study gives at least some indication that when waiting longer, the strong wish for medical treatment is likely to disappear. Smith et al. (Citation2001) report on a group of 20 young adults who started cross-sex hormones at age 16 or later age, and on a group of 14 young adults who were not deemed eligible for medical treatment due to their psychiatric comorbidity, even though they experienced GD (be it somewhat less than the treated group). Of these 14, 11 did not express any regret, 3 slightly regretted, and 1 strongly regretted not having started medical treatment.Footnote1 Moreover, on average, their GD had significantly decreased, although not as much as the treated group. This is a significant finding and gives further urgency to the question what would happen if current adolescents were not to be given puberty blockers, but if instead watchful waiting were applied, with psychosocial support, until age 16 or perhaps even 18 or 21. A recent German study similarly shows that gender incongruence may change over time, also after the onset of puberty. After 5 years, 73% of natal females aged 15–19 no longer had a gender identity disorder diagnosis (Bachmann et al., Citation2024; see also Cass Review, Citation2024, p. 29).

In conclusion, while the lack of knowledge of natural history makes it hard to observe the precise impact of medically treating GD on adolescent identity exploration and formation, interference with normal adolescent identity development is inevitable. The total body of evidence gives substantial reason to worry that puberty suppression ‘locks’ adolescents into their GD and causes iatrogenic harm by putting them on the path to lifelong invasive medical treatment (Cf. Baron & Dierckxsens, Citation2022). Similarly, starting cross-sex hormones at age 15 seems likely to hinder the resolution of GD upon further identity development.

4. The harm-benefit profile of puberty blockers and cross-sex hormones

It is a foundational norm in medicine that treatments ought to have a favourable harm-benefit profile for physicians to be justified to prescribe them. This norm directly follows from the medical-ethical principles of beneficence, which requires physicians to administer treatments that improve their patients’ health, and non-maleficence, which requires them to minimize treatment risks and harms (Beauchamp & Childress, Citation2019).

Systematic reviews consistently show that the available evidence on the benefits and risks of PBs and CSHs is inconsistent and insufficient (e.g., Cass Review, Citation2024; Ludvigsson et al., Citation2023; Miroshnychenko, Roldan, et al., Citation2025). For PBs, possible benefits concern mental health benefits, such as reduced depression and improved psychosocial function, and reduced GD. One risk of PBs concerns impaired bone development, while it is unclear to which extent this is made up during cross-sex hormone treatment following puberty suppression. Also, there are the risks regarding brain development already mentioned above (Baxendale, Citation2024). Furthermore, there are fertility risks, especially for natal males when early puberty blockage (Tanner stage 2/3) is followed immediately by CSHs. Their testes will not develop to produce sperm, causing infertility and most likely even sterility.

For CSHs, the general picture of weak evidence is comparable to that of puberty blockers, with reduced GD and depression and improved global functioning as possible benefits (Miroshnychenko, Ibrahim, et al., Citation2025). The systematic review by Miroshnychenko also reports on death by suicide, bone mass density, and sexual dysfunction, but similarly concludes that the evidence is ‘very uncertain’ about the causal effect of treatment with CSHs on these outcomes. The conclusion of this review is telling: ‘There is considerable uncertainty about the effects of [CSHs] and we cannot exclude the possibility of benefit or harm’, and the systematic review on puberty blockers by Mirosnychenko and co-authors has a very similar conclusion.

While based on these systematic reviews it thus might seem that the benefits and risks of PBs and CSHs are on a par, i.e., both uncertain, there is reason to think that most likely, the overall harm-benefit profile is negative. Medical research in general tends to significantly underestimate the risks and harms of treatments (Stegenga, Citation2020, p. Ch. 9) and this seems particularly pronounced in the domain of paediatric gender care. One of the various causes for this underestimation discussed by Stegenga is a follow-up that is too short to register harms. For example, the systematic review by Miroshnychenko and co-authors cites a study showing no difference in sexual function in natal females after 1 year on CSHs. However, another very recent study with a much longer follow-up, in adult natal males who as minors received PBs, CSHs, and genital surgery, showed clear signs of sexual dysfunction (van der Meulen et al., Citation2024). As is generally the case with systematic reviews, Miroshnychenko et al. also underreport potential harms: ‘… we […] could not address others that may be important to readers, such as regret, anxiety, pelvic pain or cancers.’ However, on some of these outcomes, concerning studies exist, e.g., pelvic pain seems frequently observed in natal females on CSHs, leading many of them to request hysterectomies for pain relief (Zwickl et al., Citation2023).

Similarly, the fertility case shows why it is important to integrate findings from basic physiologic reasoning with the conclusions of systematic reviews. Given the paucity of research on harms, there is no evidence that clearly establishes infertility. Yet, from basic biology, it is evident that testes will not sufficiently develop when puberty is suppressed early and directly followed by CSH-treatment: male patients in Tanner 2 have not developed gametes yet. This is confirmed by clinical experience and underscored by the fact that gender clinics increasingly regard fertility preservation as an integral part of their care. Clearly, infertility is far more than a hypothetical risk of medical intervention. By way of final example, one of the 55 subjects in the Dutch study that is still the cornerstone of paediatric gender care (de Vries et al., Citation2014) died from a necrotizing fasciitis directly following vaginoplasty. What this foundational Dutch study does not report, however, is the fact that PBs stunt penile growth, which makes traditional vaginoplasty in which the penis is inverted to a neo-vagina impossible. This necessitates a more complex and higher-risk surgical technique in which the neo-vagina is constructed from a part of the patient’s intestines (van de Grift et al., Citation2020). However, this death has not been reported in various systematic reviews, which testifies to the fact that systematic reviews underreport risks and harms. Accordingly, lack of decisive evidence of harm in no way constitutes evidence for a lack of harm.

In sum, while sufficient evidence on both benefits and risks generally is lacking, additional considerations give reason to give more weight to risks and harms of PBs and CSH. Infertility, for example, is a serious harm that can only outweighed by benefits supported by sufficiently good evidence. Accordingly, all in all, a negative balance of harms and benefits following early medical intervention appears most likely.

5. Non-medical interventions

It is a basic clinical and medical ethical norm that doctors should always opt for the least invasive treatment that is sufficiently effective. Non-medical approaches to GD potentially qualify as such and can include psychosocial support, awaiting further (gender) identity development (i.e., watchful waiting), treatment of psychiatric co-morbidities, and psychotherapy for treating gender-related distress. Which approach is seen as most appropriate will depend on how the relation between GD and co-occurring mental health issues such as anxiety and depression is theorized: are they just co-occurring but independent, or caused by GD, or the result from minority stress, or related in still other ways? That is a difficult issue, but in any case, the discussion here will first focus on psychotherapy and other approaches directed at relieving gender-related distress.

Nearly 30 years ago, Dutch clinicians noted that: ‘Naturally, if a complete reversal of extreme and lifelong cross-gender identity were possible by treatment methods other than SRS [sex reassignment surgery, preceded by cross-sex hormones] clinicians should refrain from SRS in adolescents, and indeed in older patients’ (Cohen-Kettenis & Van Goozen, Citation1997, p. 264). However, they already claimed that psychotherapy as treatment of GD is ineffective, and over time psychotherapy has additionally gained the reputation of being unethical, and just a form of conversion therapy (for discussion, see Zucker et al., Citation2016). In order to investigate the viability of non-medical interventions, this section will address these two prominent charges, starting with the latter.

The worry of conversion therapy is certainly understandable in the light of the history of psychiatry and transgender care. Attempts to change the gender identity of adolescents with GD in order to resolve their incongruence are likely to cause psychological harm, which may be severe. However, non-medical approaches do not need to aim to change adolescent’s gender identity towards alignment with their natal sex. Crucially, there is nothing inherently wrong with addressing the gender distress they experience, when there is no aim to change their gender identity. While it is an empirical question to what extent non-medical approaches can help adolescents to relieve their gender-related distress (while respecting their identity), prima facie this is a morally sound goal for clinicians to pursue – in fact it may be imperative, given the risks of medicalization.

And indeed, many trans persons, detransitioners, and clinicians and researchers from different perspectives are currently experimenting with ways to cope with and to reduce gender dysphoric feelings. A recent study by Lindley et al. (Citation2023) investigated, among other themes, various ways in which individuals with GD cope with their dysphoria. Their study participants reported various non-medical ways, including their choice of clothing and ‘through cognitively reframing their experiences and seeing the experience a different way’ (p. 606). The authors, working from an explicitly gender-affirmative perspective, note as a ‘practical implication’ of their findings that ‘Clinicians can assist clients to integrate mindfulness-based practices to cope with gender dysphoria’. They frankly describe ‘the ability of clinicians to intervene and reduce the distress caused by gender dysphoria’ as important for the well-being of trans persons, and they are currently working on developing such interventions (p. 592, italics added). Similarly, in a paper on managing gender-related distress by means of cognitive behavioural therapy, the authors explain that ‘we do not believe it is ethical for therapeutic work to focus on changing someone’s experienced/expressed gender but do believe that it is ethically necessary for anyone working in this field to be aiming to reduce distress’ (Canvin et al., Citation2022, pp. 3, italics added).

Further insights into ‘Alternative ways to deal with dysphoria’ can be found in the ‘Post Trans Booklet’ from the ‘Post Trans’ project.Footnote2 Many detransitioners report that treatment of co-occurring psychiatric conditions had a positive impact on their GD. Also, ‘[m]any find that meditation and mindfulness are helpful, as well as physical activities such as working out, practicing yoga and body awareness exercises’ (p. 41). As a final example, for some, active renaming of their experienced distress as just, e.g., ‘feeling uncomfortable with my breasts’, instead of ‘GD’ helped to reduce their distress (p. 46). Interestingly, there is clearly some overlap regarding the ways of coping with GD between trans persons and detransitioners, as reported by the above sources.

So far, the point has not been to claim that these interventions are proven effective, but only that stakeholders from very different backgrounds all clearly consider various non-medical therapeutic interventions to reduce gender dysphoria, including psychotherapy, as unproblematic and as (potentially) effective. This further undermines the idea that such interventions would be inherently unethical.

Moving to the second objection, how effective are various non-medical interventions? The Cass review has an insightful chapter on ’Psychological and psychosocial interventions’(Ch. 11), which also discusses the evidence on the effectiveness of psychosocial interventions specifically. That evidence is very limited since not many studies have been performed, and extant studies are of low quality (Heathcote et al., Citation2024). Noting the similar lack of good evidence for medical interventions, the review recommends ‘to explore other approaches for addressing the gender-related distress, which in itself is debilitating’ (p 155), and these approaches should be subject of well-designed studies to determine their effectiveness. Importantly, the Cass review notes that its underlying systematic review (i.e., Heathcote et al., Citation2024) revealed ‘no indication across the studies of adverse or negative effects’ (153). That does not mean that there are no such negative effects, but it is encouraging that they have not been observed so far. In addition, Cass notes that some interventions for co-occurring mental health problems are already evidence-based and should be offered to gender-distressed adolescents as well, just as they are to all other youth who need them. These interventions should be studied for their effectiveness specifically in adolescents with GD.

In conclusion non-medical interventions are potentially effective in reducing GD and in addressing co-occurring mental health problems, while not inherently unethical.

6. Alternative justifications for medical treatment of GD

In response to analyses outlining the harms and risks of PBs and CSHs and the lack of plausible evidence for (mental health) benefits, recently alternative justifications for medical treatment of GD have begun to emerge. Here, I will discuss two of them. First, a very common response is something along the lines of ‘but withholding treatment is not a neutral decision either, and likely harms adolescents with GD’. Here is a representative example:

It is important to realize that allowing puberty to progress in adolescents who experience gender incongruence is not a neutral act and may have lifelong harmful effects for a transgender young person such as stigmatization, personal physical discomfort, difficulty with sexual function, and difficulty with social integration.

(de Vries et al., Citation2021, pp. 221, italics added)

In addition, de Vries et al. point to the fact that halting pubertal development prevents the need for later invasive and expensive surgery, e.g., mastectomy and facial surgery.

Even though it is often being invoked, at its core, this argument is very weak. The harms from withholding treatment are just the mirror image of the benefits of providing treatments, and hence identical. And without plausible evidence for such benefits to follow from a treatment, there is simply no ground to offer the treatment, especially given its risks and harms. Accordingly, the appeal to potential harms from withholding treatments and framing this appeal as an additional argument is fundamentally mistaken. Consider an anticancer treatment that has no plausible evidence for overall survival gain and/or improved quality of life. It simply would not do to claim that ‘letting the cancer progress is not a neutral act, because this may shorten life and reduce its quality’.

Surprisingly, however, the ‘withholding treatment is harmful’ argument is frequently made in the literature as well as the public debate. Perhaps because PBs are very effective in suspending the dreaded puberty, some of the suggested benefits may seem so intuitive that it may appear harsh to withhold PBs to suffering adolescents. Yet professionals should not satisfy themselves with this argument but instead accept the burden of proof to provide evidence for any claimed benefits. Moreover, the argument trades on an invalid framing of the relevant clinical decision as either providing PBs (and CSHs) or withholding treatment. However, there are other options, including first offering non-medical interventions. Of course, in the meantime puberty progresses, but for all we know, this might just as well lead to the dissolution of GD in many or even the majority of adolescents.

This first alternative justification just discussed still centres on traditional outcomes, including mental health benefits, and appeals to the ethical importance of the harms and benefits of treatments. However, the second alternative justification that will now be discussed, the proposal by researchers and clinicians from the Dutch Amsterdam gender clinic, prioritizes the notion of autonomy (Oosthoek et al., Citation2024). The authors explicitly acknowledge the limited evidence base and the fact that some adolescents come to regret medical treatment. However, drawing from trans studies, they argue for ‘moving beyond the logic of improvement’: medical treatment ‘does not necessarily require demonstrating improvement to justify its provision’ (p. 16–7). Instead, they propose participatory action research to elucidate what adolescents themselves regard as important outcomes of ‘gender-affirming medical treatment’. One potential answer is reaching their embodiment goals.

There are decisive ethical problems with this proposed justification. First of all, the malleability of our bodies is rather limited. For example, if a natal girl’s embodiment goals change after CSH therapy and a double mastectomy, female embodiment goals are largely out of reach. Given the variability of gender identity over time in a substantial share of adolescents (see section III above), many will be unable to reach their altered embodiment goals. Similar considerations will apply to most of the goals adolescents might have with medical gender treatment. But more fundamentally, the proposal by Oosthoek et al. gives up on the professional role responsibility of doctors to ensure that any treatment they offer has a favourable harm-benefit profile. In other words, it gives up on their duties of beneficence and non-maleficence while absolutizing respect for patient autonomy. This reduces gender medicine to consumer medicine.

However, in medicine, respect for patient autonomy means that patients have the right to refuse medically indicated treatments, offered on the basis of their favourable harm-benefit profile. Or, in case of alternative treatment options, doctors should engage in shared decision-making, in which patients have the final say about which, if any, of the offered interventions they wish to pursue. However, autonomy is not an independent ground for offering treatment (Beauchamp & Childress, Citation2019).

To conclude, compared to a few years ago, it is certainly progress that currently virtually all participants of the debate acknowledge the significant limitations of the evidence. However, the two alternative justifications discussed are inconsistent with basic medical ethical considerations and therefore cannot serve as the basis for continuing current medicalization of GD.

7. Concluding discussion: the moral case for non-medical interventions

It is now time to draw the different pieces set out above together. First and foremost, it is striking how little weight is given by proponents of the medical gender affirming care model to the severe lack of knowledge of the natural history of GD. We have absolutely no idea about the share of adolescents with GD whose GD would (sufficiently) resolve when postponing medical intervention and awaiting further development of (gender) identity, possibly accompanied by psychosocial support and/or treatment of co-occurring psychiatric disorders. Accordingly, these children are now put on a life-long medical pathway with all its concomitant risks and harms without knowing whether this was medically necessary in the first place. Thus, to mention one important harm, many adolescents become infertile, some of them for life, without knowing whether their GD would have resolved naturally, without medicalization. The discussion in section (III) above shows that such resolution is a live possibility. Further contributing to this concern, PBs most likely are not an innocent reversible hormonal intervention to provide relief and buy time for reflection. Rather, they are an active intervention and there are plausible pathways along which they may consolidate GD.

One would expect that there were clear benefits of PBs and CSHs so as to justify harms such as infertility and many other risks, including risks to bone-mass development, brain development, etc. However, surprisingly, the evidence for a reduction of GD and for various mental health benefits is weak, too weak to outweigh the total of risks and harms flowing from medical treatment of GD in minors. While the poor state of the evidence recently has been acknowledged by most proponents of the gender affirmative care model, some of them have proposed alternative justifications for medical treatment. However, these justifications inappropriately treat respect for patient autonomy as a supreme medical ethical principle, or have other decisive shortcomings.

One very important further consideration is the changed case-mix of patients referring to gender clinics, discussed in section (II) above. While originally the medical model was developed for adolescents with childhood onset GD, from 2010 onwards natal females with adolescent onset GD became significantly overrepresented. This new type of patient also has more co-occurring mental health difficulties, and the steep rise in their number still lacks sufficient explanation. Naturally, this lack of knowledge should be further reason for caution.

Finally, doctors should always seek the least invasive treatment. Accordingly, various non-medical interventions should be the first-line treatment. While it is true that currently there is insufficient evidence of their effectiveness, they do not come with the risks and harms of medical intervention. Therefore, they should be offered first, while performing research into their effectiveness and risks is crucial.

xAI and Grok logos are seen in this illustration taken, February 16, 2025. — Reuters Listen to article

A woman has told the BBC she felt “dehumanised and reduced into a sexual stereotype” after Grok was used to digitally remove her clothing.

The BBC has seen several examples on the social media platform X of people asking the chatbot to undress women to make them appear in bikinis without their consent, as well as putting them in sexual situations.

XAI, the company behind Grok, did not respond to a request for comment, other than with an automatically-generated reply stating “legacy media lies”.

Samantha Smith shared a post on X about her image being altered, which was met with comments from those who had experienced the same — before others asked Grok to generate more of her.

“While it wasn’t me that was in states of undress, it looked like me and it felt like me and it felt as violating as if someone had actually posted a nude or a bikini picture of me,” she said.

The regulator Ofcom said tech firms must “assess the risk” of people in the UK viewing illegal content on their platforms, but did not confirm whether it was currently investigating X or Grok in relation to AI images.

The proliferation of AI image-generating platforms since the launch of ChatGPT in 2022 has raised concerns over content manipulation and online safety across the board. It’s also contributed to an increasing number of platforms that have produced deepfake nudes of actual people.

In a related development, Grok on Friday blamed lapses in safeguards had resulted in “images depicting minors in minimal clothing” on social media platform X and that improvements were being made to prevent this.

Screenshots shared by users on X showed Grok’s public media tab filled with images that users said had been altered when they uploaded photos and prompted the bot to alter them. “There are isolated cases where users prompted for and received AI images depicting minors in minimal clothing,” Grok said in a post on X.

“xAI has safeguards, but improvements are ongoing to block such requests entirely.”

Though backers of "sex worker" unions claim the groups promote rights, the women I interviewed seemed anything but empowered. (Pictured, Cambodian prostitutes.)

Prostitutes in Phnom Penh, Cambodia. (AP / David Longstreath)

During a trip to Cambodia in the summer of 2015 I came across a well-funded NGO that purported to run the largest union of “sex workers” in Southeast Asia. In Phnom Penh, I had arranged to meet a group of women who were, I was told, members of the “sex workers” union that had been founded by the Women’s Network for Unity (WNU). The WNU, which received funding by the Open Society Foundation, a multibillion-dollar fund set up by the investor George Soros, has a clear pro-prostitution agenda.

Our meeting was scheduled for 8 a.m. I brought with me a translator from another Cambodian women’s NGO. On arrival at the venue, I was surprised to find that a board member of the WNU had also decided to attend.

The women arrived, and, despite the fact that they had been out all night dealing with sex buyers and pimps, were warm, open and keen to talk about the violence and abuse they endure from sex buyers and police.

The board member interrupted them regularly, often speaking for them. I asked “What are the benefits of being in the union?” She answered on their behalf: “If the women are beaten up by the police, they are given legal training on their rights; if they are arrested, the WNU will provide food during the time they cannot work; and if one of the women dies, they will help to buy the coffin.” She concluded that “knowing their rights empowers them.”

The women seemed anything but empowered. One told me she could get out of prostitution only if she had $200 to buy formal identification papers, because this was the only way to secure legitimate employment in, say, the service industry or a factory. The other women joined in, saying this is also what they needed and wanted. They hated prostitution, they said.

WNU representatives claim they have 6,500 Cambodian “sex workers” on their books fighting for “sex workers’ rights.” The translator said that none of the women I met with used the term “sex work” to describe what they do, or “sex worker” to describe who they are. This language was used by the WNU. One of WNU’s aims is “to challenge the rhetoric around sex work, particularly that concerned with the anti-trafficking movement and the ‘rehabilitation’ of sex workers.” All the women asked me where they could get help to escape the hell they were in. Meanwhile, WNU board members and paid staff travel the region, speaking at “sex workers’ rights” conferences, distorting the voices of exploited women.

The prostituted women in Cambodia made it clear to me how much they hated prostitution. The board member said she had been at a regional conference with other “sex workers’ rights” activists and that “tens of thousands” of “sex workers” in Cambodia signed up to this so-called union. The women I spoke to had no idea that they were “sex workers’ rights” activists.

The experiences of these women were being used by WNU to promote the idea that unionization and decriminalization—a result of prostitution being formally recognized as labor—would solve all problems, despite the fact that the worst violence described by the women was by sex buyers. This NGO considered the concept of “sex workers’ rights” to be above and beyond the importance of the lives of the women themselves. I asked the board member if WNU was planning on raising money to help the women out of prostitution. She said “No.”

A documentary on prostitution in Cambodia titled “(Sex Workers Cry) Rights Not Rescue in Cambodia” is described as a collaboration between the 6,400-member WNU Cambodia and Paula Stromberg, the filmmaker.

The coordinator of WNU is interviewed for the film, and says: “WNU is an association of sex workers—adult women, men and transgender people. We choose to work. We are not victims. We are not trafficked. No one owns us. We don’t have pimps. No brothel owners enslave us. We do not want to be rescued.”

I found this statement quite difficult to process, having spent time in Cambodia speaking to prostituted women, pimps and bar owners.

In an email exchange with me, Stromberg wrote: “I would find it presumptuous for me as a Canadian to speak on behalf of the sex workers here in Cambodia. That is often the source of their problem—that everyone wants to speak about them, but few want to listen their voices.”

But as I had discovered in Cambodia, the WNU does speak for “sex workers,” literally putting words in the women’s mouths.

By the time I visited Cambodia I was very familiar with sex work lobbyists’ oft-adopted tactics of presenting pro-pimp organizations as “sex workers’ unions.” In 2002, the front page headline of a London newspaper read, “Sex workers to join trade union.” I had heard about the campaign, organized by pimps and their sympathizers in the U.K., to formally declare prostitution as “work,” but was nonetheless surprised that any credible trades union had bitten the bullet.

Britain’s third biggest union, the GMB, which was formed in 1889, had been persuaded by lobbyists for legalization of the sex trade that prostitution is a job, and that those selling sex deserve “worker’s rights.” In January 2002, to a fanfare of publicity, the Adult Entertainment branch was officially sanctioned by the GMB.

The Adult Entertainment branch began life as the International Union of Sex Workers (IUSW)—the brainchild of two academics who were not involved in prostitution. The IUSW—now operating mainly as a website—has never been a union, but a lobbying group for the decriminalization of pimping. Academics, sex buyers and pimps were welcomed as members of the IUSW, which eventually led one of its more leftist members to break ranks and spill its secrets to me.

In the early days, two gay men were the main spokespeople for the IUSW, making their rather unrepresentative voices dominant in the “sex worker’s rights” debate. One of them, Douglas Fox, a Conservative Party activist and co-owner of a large “escort agency” based in northeast England, was also an activist for Amnesty UK. In 2008, Fox proposed a motion for blanket decriminalization of the sex trade at the Amnesty International (AI) Annual General Meeting, a proposal that became international AI policy seven years later.

Thierry Schaffauser was prostituted on the streets of Paris as a teenager before moving to the U.K. Schaffauser became involved in “worker’s rights” campaigns, moved to London and joined the IUSW, soon rising to the role of president. But Schaffauser was unhappy with Fox being the public face of the organization, and, despite being warned not to speak to me about his views (other members were aware that I was researching the IUSW for for a news article), gave me an on-the-record interview. Partly as a result of this interview, Schaffauser was kicked out of the IUSW.

Lobbyists use the term “sex work” to include not just people directly selling sex, but also pimps, brothel owners, pornography producers and distributors, brothel security, sex trade propagandists, academics who research prostitution and even taxi drivers and advertisers.

The support of Amnesty International and other so-called human-rights-based organizations that advocate for decriminalization of the sex trade in the affluent West has a significant influence on sex trade policy and legislation in the Global South.

In the Netherlands, I have investigated the Red Thread, a now-defunct “sex workers’ rights” organization that masqueraded as a union until its collapse. Founded in 1984, it was funded by the Dutch government from 1987 with a mandate to combat HIV/AIDS. Red Thread closed in 2009, four years after losing its government funding.

At its height, however, the Red Thread had only 100 members out of an estimated 25,000 prostituted people across Holland. It never fought a case on behalf of a “worker” in court, and made no tangible difference to the “working” lives of prostituted individuals. It was a propaganda machine for legalization, and ensured that the Dutch were seen as “cutting edge” in their approach to complicated social problems. The Red Thread lost its governmental backing at the same time the international media began to report on evidence coming out of Holland that showed how legalization had been an unmitigated disaster.

But the damage had been done, and, in the true spirit of colonialism, the campaigners in the Global North that had run well-oiled propaganda machines, peddling the benefits of unionizing and legalizing the renting of women’s orifices, spread their influence to the Global South.

In India, the NGOs adopt the same tactic, and give red umbrellas—the symbol of the “sex workers’ rights” movement”—to the women standing outside the brothels waiting for trade. They want the women to march around Sonagachi, Kolkata—India’s biggest street prostitution zone—with their red umbrellas. “The pimps run these movements, and the prostituted women have no say in it at all,” says Ruchira Gupta, founder and president of Apne Aap Women Worldwide, an organization in India working to end sex trafficking.

“One day, in the late 1990s, there were female pimps seen around Sonagachi, speaking as ‘sex workers’ and claiming they were empowering the women in the brothels by forming unions to protect their rights in the workplace,” Gupta says. “But these women do not have any ‘rights’ in prostitution, and the ‘union’ was simply helping the pimps call for legalization.”Gregor Gall is an academic based in the U.K. whose specialty is the unionization of “sex work.” He has written two books on the topic, and it is clear that Gall has done his research. I asked Gall if he had come across any bogus, pimp-led “unions.” He admitted that he knew of one in India, and that it is likely they exist elsewhere in the Global South.

“There’s a union there [probably in Mumbai] for bar girls, meaning prostitutes,” Gall says. “It was set up by a non-sex worker … and there was evidence that the bar owners helped fund it because the bars were being closed down.”

Terms such as “collective” disguise the true nature of organizations that claim to be unions but in fact exist for the benefit of the johns, pimps and brothel owners.

SWEAT (Sex Workers Education and Advocacy Taskforce) is the leading pro-prostitution NGO in South Africa, founded in the early 1990s by two white “sex workers’ rights” activists, Shane Petzer, a gay male sex worker, and Ilse Pauw, a female clinical psychologist. Like other pro-prostitution NGOs, SWEAT uses the international language of human rights to argue for decriminalization.

“I looked at their leaflets, and saw cartoon drawings of happy looking women,” a woman who had recently exited the sex trade told me when I was in Cape Town in 2016, “and there were [speech] bubbles coming out of their mouths saying things like, ‘My union protects me,’ and ‘I can enjoy my job like anyone else,’ and it made me feel bad for [wanting] to leave prostitution. I thought it must be something wrong with me not to be enjoying it.”

SWEAT has been actively campaigning for decriminalization of the sex trade since 2000.

“To them it’s just [an] agency to sell sex, it is just work, ‘sex work,’ ” says Dudu Ndlovu, a gender studies student who was previously a volunteer at SWEAT. “To be a black woman and be prostituted in post-apartheid South Africa is to be reminded that you’re nothing, when we are now supposed to be liberated. SWEAT says that prostitution is your individual choice, and that there is no difference between my choices and yours,” Ndlova continues, “which is ridiculous, because you are a white woman living in the West and I am a black South African.”

Many of the so-called unions often appear to be set up as worker’s rights organizations in order to look attractive to funders.

George Soros’ Open Society, which funds the WNU in Cambodia, is one such group that looks kindly upon organizations claiming to help “sex workers” organize and achieve autonomy. The Open Society gives generously to SWEAT, and to other pro-prostitution NGOs in the Global South, such as those in Kenya, Cambodia and India.

Mickey Meji is a survivor of the sex trade and runs an exiting service in Cape Town for women who wish to leave prostitution. I ask Meji during my trip to Cape Town whether she believes it is possible to unionize the sex trade. “No,” Meji says, “because in South Africa the trade unions that we have, as far as I am concerned, represent people who are recognized as workers.” Meji is referring to domestic workers in South Africa, who are often ill-treated, underpaid and abused by employers, and, until the early 2000s, had no employment rights.

“People can unionize before they are legally recognized as workers,” Meji says. “We started having ‘house helps,’ and the employers decided what they wanted to pay and they [workers] decide if they want to accept it. Finally, through unionizing, they fought for the recognition of their rights. It was not a criminal offence to be ‘house help.’ That’s the difference; otherwise we’ll start having a union of smugglers and traffickers.”

I ask Meji: What if prostitution was legalized? She believes the stigma of being prostituted will never leave female prostitutes, even if there are no criminal penalties attached. “How do you unionize people in their absence?” she says. “When they march they wear masks; they want to be hidden and anonymous. How do you then unionize that? Because every industry that we know of, regardless of how gruesome it is or how dirty it is, people have taken ownership. But in the sex trade there is no real ‘pride’ from the women being prostituted.”

Janet M. Wojcicki, a white anthropologist based at the University of California, appears to consider black Africans such as Mickey Meji to be motivated by religious fundamentalism. In an article on the pro-prostitution movement in Gauteng Province, South Africa, in the early 1990s to 2000s, Wojcicke makes the extraordinary claim that, post-apartheid, “There is now a counter discourse opposing decriminalization, based on religion and on the argument that sex work is ‘un-African.’ ” The feminists opposed to the sex trade on the grounds that it is both a cause and a consequence of women’s inequality are neatly written out of the debate by Wojcicki. The sex trade can never be unionized because prostitution is not labor. Beatrix Campbell is a socialist, feminist and author of the classic text, “Wigan Pier Revisited” (1984).

“In all of the discourses about prostitution as work—is always—what the product is, who buys the product and what the relationship of this alleged purchaser is, in relation to power over and power to,” Campbell says. “That’s the other half of the discourse that needs to be explored. What do men think they’re doing when they are buying sex?”

The Russian Federation, which borders Europe and Asia, boasts a massive sex trade, and is known as a hub for pimps and traffickers.

Irena Maslova is the coordinator of Silver Rose, an NGO in Russia that campaigns for a legalized sex trade. Maslova told me, “I have 3 million sex workers behind me [across Russia].” Silver Rose was founded in 2003, and at the time was a small advocacy organization. By 2011 it was well funded, partly by George Soros’ Open Society, and expanded to 30 cities around Russia.

“Silver Rose is more a supporting role and promoting the idea of unionizing and getting together in order to stop the situation of violence and discrimination against sex workers,” Maslova tells me. I ask how many people in prostitution are in her union. “We have 3 million sex workers behind us,” she repeats.

Yet I have found no evidence of any employment tribunal finding, or any positive stories about the unionization of prostitution during my extensive research. Nor did any of the formerly prostituted women I interviewed from across the Russian Federation know of such a “union,” let alone say they’ve benefited from it.

The occupational hazards of regular workers are not remotely similar to those faced by women in the sex industry. Drug and alcohol misuse, violence in the “workplace,” unwanted pregnancy, sexually transmitted diseases and even death are daily concerns for many prostituted women, not the extraordinary issues they would be for regular workers. Prostituted women deserve human rights, not “workers’ rights.”

Janet Wojcicki claims that “… if one examines the language that is used in speaking and writing about sex work and sex workers in the post-apartheid period, it becomes clear that the movement to decriminalize sex work has incorporated the overall language of human rights that became enshrined in the African National Congress’ Constitution.”

But Nozizwe Madlala-Routledge, former ANC activist and founder of the feminist anti-prostitution (abolitionist) NGO Embrace Dignity, based in South Africa, has a very different take on this.

A man dressed as a woman was arrested in Virginia on Monday after police say he was caught peeping into restroom stalls three times in the past year.

Richard Rodriguez, 30, filmed a woman in a bathroom stall at the Potomac Mills Mall, Prince William County Police said on Tuesday. A 35-year-old woman was in the stall when she saw a bag moved toward her under the stall divider. Rodriguez apparently had been filming her, police said.

The victim rushed out of the stall to confront the man and saw him hurry to another stall, next to another woman. The victim alerted the woman and then contacted mall security of the shopping center on 2700 block of Potomac Mills Circle in Woodbridge, Virginia.

Photo of suspect in May 15 and Oct. 11 peeping incidents

Mall security detained Rodriguez until police arrived. Police then determined that he matches the description of a man who is accused of using a mirror to see into a women's restroom stall on May 15 at a nearby Walmart and also at the Potomac Mills Mall on Oct. 11.

The suspect in the May 15 incident allegedly spied on a 53-year-old woman, police said. The suspect in the Oct. 11 incident -- believed to be the same man -- looked in on a 35-year-old woman and her 5-year-old daughter.

In 1931, a condition called “premenstrual tension” was described for the first time in a scientific study by gynecologist Robert Frank. His advice for women with severe cases of premenstrual tension? Radiate the ovaries, or completely remove them. Fast forward 80 years and the treatment of premenstrual syndrome (PMS) hasn’t progressed far from this drastic approach. Yes, as a last resort, women with extreme PMS still opt to have their ovaries taken out. If removing an entire organ sounds archaic, it is, but there’s a reason why this still happens in the 21st century.

For decades, PMS, its causes, and the question whether it is actually a medical condition have been shrouded in mystery. PMS is a complicated health problem as symptoms and severity differ in every woman and, even in individuals, often vary from month to month. This makes it difficult to study and has led to a vicious cycle developing in PMS research – scientists don’t understand what causes PMS, meaning there is little scientific research into it, and, in turn, less funding for new studies.

What’s known is that PMS has to do with hormone changes during the luteal phase of the menstrual cycle. Chemical changes in the brain – a reduction of serotonin triggered by these hormone change – may also play a role in PMS. So may lifestyle factors like stress and diet. Others may have a genetic predisposition to PMS, psychologist Carolyn Janda says.

To put how little research has been done into PMS into context, a search of titles and abstracts on ResearchGate found there are over five times more studies into erectile dysfunction than into premenstrual syndrome. That’s despite the fact that approximately 19 percent of men experience erectile dysfunction over the course of their lifetime, while over 90 percent of women report some symptoms of PMS.

Defining the symptoms is where the problem of researching PMS starts. Researchers still don’t agree on what the symptoms of PMS are – over 150 are commonly listed, from the predictable bloating and mood swings, to headaches, sleep disorders, and even clumsiness.

This lack of consensus means women are often unsure which symptoms they can actually attribute to their period, and which are unrelated. This also makes treatment – let alone finding a cure apart from hysterectomy – difficult. Treatment currently includes taking a class of antidepressants, selective serotonin reuptake inhibitors, to easy emotional imbalances. Hormonal contraception is commonly used too. There’s also evidence that certain alternative treatments help alleviate symptoms, including chasteberry. However, over 40% of women who have PMS do not respond to treatments currently available, and five percent have premenstrual dysphoric disorder (PMDD), a condition so severe that 15 percent of sufferers attempt suicide at some point in their lives.

Figure: Schmelzer et al. in Health Care For Women International 36

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“When I experience intense bouts of PMS that include a combination of lethargy, irritability, difficulty concentrating, mood swings, anxiety or crying spells, seemingly simple things like getting out of bed or talking to more than one person at a time can feel like a feat,” said one woman. Symptoms like hers have tragically been confused with, and diagnosed as bipolar disorder.

“I suspect that this is a fancy way of saying it’s really just in a woman’s head”

According to PMS researchers, patient stories like these are unlikely to change until the science gets taken more seriously and receives more funding from institutions. Kathleen Lustyk, a psychologist from the University of Washington, has had grant reviews rejected on the grounds that PMS does not actually exist. Her reviewers suggested it was “merely a product of our society or culture that has painted a natural process in a negative light and that, given its monthly predictability, leads to suffering through anticipation.” “I suspect that this is a fancy way of saying it’s really just in a woman’s head,” Lustyk said. That’s despite the fact that PMS can affect women’s lives far longer than a couple of days per month – for example, symptoms of anger or anxiety can wreak havoc on relationships for years to come.

However, investment in research isn’t the only key to improving what we know about PMS.  Researchers struggle to compare results across studies. The International Society for Premenstrual Disorders, a group of researchers and medical professionals working on women’s health, recently released a consensus to standardize the diagnosis and management of PMS. They recommend women keep a diary recording symptoms for at least two months. Period tracking apps like Clue could help to do this. Women use the app to record how their bodies change over the course of their menstrual cycle, including physical and mental symptoms. This information, the company says, is already attracting a lot of interest from medical professionals.

Two men kidnapped an eight-year-old girl and gang raped her for seven days in Pakistan. They later strangled her.

Receiving an anonymous tip about the crime, police raided a bus and arrested the two men, one dressed as a woman. He told the police that “he and his accomplice had abducted five minor girls and killed them after subjecting them to rape.”

They confessed to kidnapping the girl, raping her for seven days, and strangling her. But one official said that “the victim might have died due to profuse bleeding that resulted from repeated rape.”

The news comes only days after the Society for the Protection of the Rights of the Child found that at least “10 cases of child sexual abuse took place every day in 2015, bringing the total to 3,768 cases in the last year.” The researchers found that 21 percent of girls married before they turned 18 years old. They also accused the government of failing “to formulate policies and legislation that would work towards eliminating child labour.”

The media reported the Council of Islamic Ideology (CII) considered a bill to outlaw pedophilia as “anti-Islamic” and “blasphemous” in February. The bill outlaws underage marriages and “recommended harsher punishments for those entering conjugal contracts with minors.” CII Chairman Muhammad Khan Sherani said Islamic laws say “marriage can be solemnised when a girl attains puberty.”

In January, four wealthy men kidnapped and gang-raped a seven-year-old boy. Officials said the men, while drunk, kidnapped the young boy and took him back to their settlement. They killed him with a rope after they raped him.

Two months later, the police rescued a nine-year-old girl from an arranged marriage to a 14-year-old boy in her village in Punjab province. They arrested four village elders responsible for the wedding.

“The girl’s brother’s wife died due to some health problems a few weeks ago, and (the wife’s) relatives suspected foul play and accused her family of murder,” declared deputy superintendent of police Mamoonur Rasheed. “On March 3, the village council decided to give the little girl in vani to settle the suspected murder.”

“Vani” means child marriage, which is common in Pakistan “to build and strengthen alliances, settle disputes or pay off debts.” Pakistani law does not allow children to marry under the age of 16, but most thwart the law and marry off their children. Police rarely intervene in these family matters.