Yesterday I posted a piece on a news report about the World Health Organisation’s recategoration of “gender identity disorder” as “gender incongruence,” and was taken to task by a new commenter, Nick Townsend. I’ve decided I can give a more adequate response to his well-argued post in a new OP rather than in the limited format of the comments software.
Firstly, let me state my position upfront: I profoundly believe in gender identity disorders, but am unapologetically a trans-gender denier. In other words, I fundamentally disagree with the WHO spokeman in the BBC report:
A World Health Organization expert said it now understands transgender is “not actually a mental health condition”.
Nick complains of a lack of compassion in the post, but there is a time for responding emotionally, and a time for questioning the realities behind the emotions. And, I would suggest, when transgender issues are being forced on civil society almost entirely through polemics by politicians, news media and aggressive activists, there is also a place for counter-polemic.
A decade ago, I was governed by the need to counsel actual people with gender identity problems, and to struggle to get them referred to the single available “expert” unit by tertiary referral via our consultant psychiatrists, who in turn felt constrained in their own ability to intervene by the “specialist” nature of the condition, and also struggled to contain the patients’ problems whilst waiting interminably for the tertiary centre to take over their management.
I had no alternative referral options whatsoever, and so my dealings with patients were predicated on, necessarily, endorsing the policies of the tertiary centre, which were strong on drastic interventions, taking the patients’ perceived gender as a given truth, and decidedly weak on any deep exploration of the psychological reasons for their belief. My anecdotal experience of severe ongoing problems with a good proportion of our patients who had actually undergone the standard treatment was at odds with the received wisdom that they did well.
I am now retired, and am in a position to look at the situation more dispassionately – and, as previous posts have addressed, in the light of my half-forgotten training in social psychology at around the time when the concept of “gender” (as distinct from “sex”) began to be developed by sociologists.
It is a rare condition: the baseline in childhood/adolescence is, I believe, around 0.07%, and is probably less afterwards since so many resolve (Cohen-Kettenis PT, Delemarre-van de Waal HA, Gooren LJ. The treatment of adolescent transsexuals: changing insights. J Sexual Med 2008;5:1892–1897). I am therefore unlikely to encounter such individuals again, and if I do, it will likely either be pastorally rather than medically, or in the guise of trans-activists – in which case “compassion” is not likely to be demanded so much as surrender.
So, to Nick’s specific points:
1: At least from the links Jon supplies, neither the BBC report nor the WHO announcement appears to use the term “gender dysphoria” but only “gender incongruence”.
I did try to interpret, from the limitred information in the report, how the WHO was moving the game along. ICD-10, and dependent national indices, had already reclassified the problem from a “disorder” to a “dysphoria,” the latter being defined as “a state of unease or generalized dissatisfaction with life.” This change was made with the specific intention of distancing the condition from any pathology and seeing it as an emotional state, whilst still enabling it (somehow) to be treated by medical and surgical interventions as if it were a pathology. Such a situation was, and still is, a conundrum.
This, I think, covers Nick’s second point: the term “dysphoria” leaves entirely moot the causation of the unease – and that’s precisely why many trans-activists have insisted it should be changed again. Their contention is that all the distress is caused, directly or indirectly, by gender mis-assignment at birth, and not from any medical or psychological condition. They would see it as the equivalent of parents who mistakenly raise their child as a dog: the problem is not with the sufferer but with their external world.
Whether the WHO’s suggestions for ICD-11 are a step further in de-medicalising it to an “incongruence” or whether the BBC is simply using the word as a synonym for “dysphoria” is, as I said in my piece, immaterial – both terms are intended to make transexuality a variation of medical normality, and not a health problem in itself, whilst enabling it to be treated medically. In an article elsewhere, the expert in the BBC piece, Dr Lale Say, states:
“So, in order to reduce the stigma while also ensuring access to necessary health interventions, this was placed in a different chapter.”
In her view, and presumably that of the WHO, the “stigma” comes purely from regarding the condition as the sufferer’s problem, rather than ours, just as a racial minority has no inherent problem until stigmatized by the prejudice of others.
3. Logically it does not follow that, if the condition not a disorder, the gender assigned at birth is merely a social construct.
In my essay, I was dealing with the logic of the reported content of WHO’s ICD-11:
Gender incongruence is defined as a marked and persistent incongruence between a person’s experienced gender and assigned sex.
“Assigned” is the weasel-word here. Historically, one does not “assign” (= specify or designate) a person’s sex any more than one assigns the number of their legs: one observes a biological fact. “It’s a boy, Mrs Walker!” And not “Let’s call it a boy.” So the WHO definition only makes sense in the context of the 1960s concept of a separate “assigned gender” popularised by the Frankfurt’s School’s philosopher Herbert Marcuse and brought into paediatric medicine by John Morrow at John Hopkins University. That’s the stuff I learned about in 1973, then mainly forgot, but it rests on questionable assumptions.
Certainly, if WHO were dealing with transgender as a “third sex,” Nick’s alternative suggestion, it would be resting on no intellectual foundations at all (and given the escalating range of claimed gender-identities, would be flying in the face of patient perceptions too). The existence of two sexes is based on universal human experience both of their own kind and the biological world. Biologically sex corresponds to reproductive function, sociologically to marital traditions, and creationally, in Christian terms, to some complementarity in mankind as God’s image.
Scientifically, sex corresponds to measurable anatomical, physiological, psychological, chromosomal and genetic facts that scientific medicine relies on in order to meet the claim to be evidence-based. Gender dysphoric people, in the better studies, correspond to all these sex criteria of sex, except for their self-assessment. If they did not, they would clearly be suffering from a disorder of those criteria. Rare intersex patients are the exception that proves the rule: they suffer defined physical disorders, but usually are content with their self-identity even without treatment.
A third sex would need to correspond to some biological function, in the real world, and it is hard to see how any such function could be met by 0.07% of the population. It must also correspond to some factual distinctions, or it would be meaningless: one might as well claim that chess players are a third sex.
As it is, it is hard to see on what “natural” basis (that is, amenable to science) gender-identity separated from physical sex rests. Where does this gender reside? I joked about the idea of a gendered soul, which would certainly be beyond the remit of the WHO as much as any other concept of soul, but if not that, what other scientific concepts are available for an intrinsic (as opposed to pathological) identity opposed to biology?
4: Appealing to (a) a general claim (“large numbers”) and (b) anecdotal evidence, even from experience within medicine, isn’t good enough.
That is ideed true, but broader evidence was implict in what I said, some of which I have referred to in previous posts. In terms of the associated pathology, the large study Nick himself cites by Dhejne et al, which was (and may still be) the only long-term follow-up of an entire national cohort (Sweden) that had been done using a control group, showed this:
Dhejne and colleagues found statistically significant differences between the two cohorts on several of the studied rates. For example, the postoperative transsexual individuals had an approximately three times higher risk for psychiatric hospitalization than the control groups, even
after adjusting for prior psychiatric treatment. (However, the risk of being hospitalized for substance abuse was not significantly higher after adjusting for prior psychiatric treatment, as well as other covariates.) Sex reassigned
individuals had nearly a three times higher risk of all-cause
mortality after adjusting for covariates, although the elevated risk was significant only for the time period of 1973 – 1988. Those undergoing surgery during this period were also at increased risk of being convicted of a crime. Most alarmingly, sex-reassigned individuals were 4.9 times
more likely to attempt suicide and 19.1 times more likely to die by suicide compared to controls. “Mortality from suicide was strikingly high among sex-reassigned persons, including after adjustment for prior psychiatric
morbidity.” (Sexuality and Gender Findings from the Biological, Psychological, and Social Sciences
Lawrence S. Mayer, M.B., M.S., Ph.D. and Paul R. McHugh, M.D., 2016)
On the proportion of patients desiring to detransition, the research has not been done. And one reason is in the experience of a transgender-counsellor who was blocked from exploring it, James Caspian. A brief interview with him is here. Longer interviews are also on YouTube – but bear in mind that he himself is gay and has been immersed in the gender-identity culture of the same clinic I used, for many years.
That culture has been challenged even by its own governor. Another news report this year, not to hand, speaks of work stress, resignations and a culture of fear there because of disquiet over the massive increase in child-referrals and the guidelines to proceed to transition without serious investigation. I hear the same from medics in the USA, so it is not just a rogue clinic, but the international guidelines.
Nick also cites the study by T. van de Grift et al, but this (like most others) predates the Swedish work (it covered evidence from 2007-2009) and has profound methodological shortcomings: firstly, patients were invited by questionnaire, and only 37% responded – making 63% lost to follow-up (including, of course, any who might have committed suicide!). Secondly, there was no control group. Thirdly it measured responses only 4-6 years after initial contact, whereas the Sweden study showed that, whilst dysphoria was indeed relieved <10 years after surgery, it was the long-term results that profoundly altered the situation. So (and this is the case with nearly all current studies) cases were self-selected, lacking controls, and short term.
So my contention, whilst I didn’t document it in the OP, was more than merely anecdotal: what is significant in my own anecdotal experience is that it reflects the best study, and points to the gaps in the research that cries out to be done, but cannot because (a) activism prevents it and (b) once a group has been authoritatively defined as normal, eg by the WHO, it will be considered unethical to research causation, or to suggest that there are ill effects long-term related to that normality. One is therefore bound to conclude that any long-term detrimental effects are caused by stigma and prejudice rather than by the condition itself. This cannot help either sufferers or society as a whole, if it happens to be wrong.
5: Gender dysphoria is a terrible condition to experience, no doubt.
And this is why I see the WHO position, in treating it as an “incongruity” under the banner of “sexual health,” as encouraging – no, constraining – the medical profession and the politicians to treat suffering people with dangerous and ineffective treatment, making an “oppressed community” out of those who are actually isolated from reality by their beliefs.
A comparison. Far more common than patients with gender problems are those who regard themselves with general disgust and self-hatred. “Lack of self-esteem” is too mild a term – these people have grown up with the firm belief that they deserve no place in the world. They suffer from depression, anxiety, suicidal ideation and consequently their fears of failure become confirmed in poor relationships, financial hardship and all the rest. Yet they are, in reality, physically healthy and normally intelligent individuals.
The causes of their self-dislike are not that hard to find – virtually always there were early problems in parenting, abuse, deprivation and so on. Yet even knowing this, their problems tend to remain intractable: there were such patients I befriended at the start of my GP career who, despite all interventions from psychotherapy, medication, and so on, remained highly vulnerable when I retired.
Yet whatever improvement they showed was achieved by helping them to understand the reality of the root causes of their “disorder.” And, indeed, by their coming to see that they needed, somehow, to change their beliefs about themself if life was to get any better. Sometimes there were indeed dramatic turnarounds, when patients realised what had damaged them, and managed to put it behind them and move forward. On more one occasion, it was the prayer of believers in the name of Jesus, who had no therapeutic knowledge at all at their disposal, that made the difference.
The very last thing one would do in such cases, obviously, is to take the deep-seated belief of the patient at face value. We would never affirm their lack of worth unless we desired to do them harm. Even if one knew nothing of their past life (and they had suppressed all the bad memories), one would affirm that, at core, they are as other men and women, and that the problems they have are a disordering of that truth. Their beliefs are dreadfully deep-seated, but it is their beliefs that are the only real intruder on their well-being, and the healing of their beliuefs that is the only long-term hope.
At a different extreme, there seems no reason to say that the beliefs of a paedophile, that his orientation towards children is intrinsic, are any less convincing to him than that of any other sexual orientation. Certainly, in the days when paedophilia was an integral part of the civil liberties agenda (search also on Foucault and Cohn-Bendit), it was held to be the case that social prejudice was what forced paedophiles to be devious and manipulative. It is certainly true that even long prison sentences and the risk of death or injury from vigilante groups seem, all too often, not to change the desire.
To more recent (and commonsense) sensibilities, it seems that there is a clear conflict between such desires and inevitable harm to children, with which I trust few of us would disagree; and so society demonizes paedophiles like no other group. I’ve never heard a Christian say that God made paedophiles as part of the rich variety of his creation, and with good reason. Rather, we regard their belief as we would a cancer of their soul. Hopefully, we pray for their healing and forgiveness: an interesting balancing act between justice and compassion, as more than one archbishop has found in recent years. Such cases are where the rubber of Christ’s love hits the road.
But the WHO has no more scientific warrant to dismiss the validity of the paedophiles’ belief in what they are innately than to accept as valid any other scientifically unsubstantiated belief. If Foucault’s 1969 letter to the French government, signed by many intellectuals, had succeeded in abolishing the age of consent, perhaps paedophilia too would appear in the ICD chapter on sexual health.
I only make a comparison of gender dysphoria with paedophilia to show how, in practice, the medical profession does not accept all subjective beliefs as valid, even when the believer regards them as blameless – just as the medical profession does not accept the self-blame of the “heartsink patient” as valid.
But it is not only that I disagree with the WHO’s assessment of gender dysphoria – in itself a morally blameless condition, until mixed with politics, identity activism and coercion – but that by exerting its worldwide authority in this way the WHO locks all of us into a certain way of looking at the condition, and at matters of gender overall, in an unproductive and false way. Worse, it asks us to believe, by a logic I still can’t fathom, that what is not a disease is mandatorily to be treated by life-changing medical and surgical interventions.
In this way reality itself gives way, on medical authority, to personal beliefs, and that is problematic for us all.