Ten Critical Ethical, Conceptual, and Clinical Cautions Concerning the Diagnosis and Treatment of Gender Dysphoria and Transgender Identification

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Abstract

There is an urgent need for ethical, conceptual, and clinical clarity regarding the diagnosis and treatment of gender dysphoria and transgender identification. In this essay, I highlight ten critical concerns in this arena, namely, those involving: (1) conceptual parallels between sexual reassignment surgery and elective limb amputation; (2) the lack of long-term data that demonstrates reliable long-term relief from gender dysphoria in those undergoing hormonal or surgical treatment for gender dysphoria; (3) special problems with informed consent in the context of “gender affirming” treatments; (4) the importance of very high desistance rates of gender dysphoria and transgender identification, particularly in children, even without treatment; (5) the extensive differential diagnosis and the need for thorough and subtle assessments in the face of gender-related complaints; (6) a deep religiously based objection to transgender ideology involving the ordering of creation; (7) controversies concerning the existence of rapid-onset gender dysphoria; (8) the recent depathologizing of gender dysphoria; (9) the roles of genetics and environment in transgender identification and gender dysphoria; and (10) reflections on the role of psychotherapeutic treatment in patients with gender dysphoria and transgender identification.

Keywords: transgenderism, gender dysphoria, transsexualism, sexual reassignment surgery, gender affirming care

Introduction

Many clinicians, friends and family members, scholars, and other interested parties who are unfamiliar with the clinical, conceptual, and ethical complexities concerning how best to approach those with gender dysphoria (GD)[1] who identify as being transgendered not infrequently are under the mistaken impression that the optimal clinical response to all gender dysphoric patients with transgender identifications is simply a matter of encouraging these patients in the gender-specific directions of their choice.[2] These individuals also often harbor the mistaken impression that a clinician’s task of identifying who is, and who is not, “transgendered,” in the relevant sense, is a simple matter of asking people with which one (or more) of a large and growing number of genders, if any, they identify. Unfortunately, even among mental health professionals, the kind of comprehensive clinical investigation and conceptual rigor that is required for the proper diagnosis and ethical treatment of GD and transgendered individuals—and the clinical and ethical problems these conditions pose in clinical contexts—is not often optimally, or even adequately, undertaken. I have, therefore, very briefly enumerated ten clinical, conceptual, and ethical concerns that anyone who is treating, or is otherwise involved in the care of, gender dysphoric and, more narrowly, transgendered patients, or anyone who simply cares about these troubled individuals, ought to consider in the context of their clinical work, in the context of their family or, more broadly, social interactions with transgendered persons, and in attempts to forge a coherent philosophy regarding how to think clearly about the ethical and conceptual challenges posed by these individuals, many of whom are suffering in the extreme and are in desperate need of clinically and ethically sound, compassionate responses from their clinicians, their families, and their friends.

I. Conceptual Parallels

First, the ethical propriety of one’s seeking, as a reaction to one’s GD or cross-gender identification, amputation of perfectly healthy breasts or external genitalia by way of Sex Reassignment Surgery (SRS, also referred to as “Gender-Affirming Surgery”) appears, conceptually, to entail the ethical propriety of those persons with Body Integrity Identity Disorder (BIID) undergoing amputation of perfectly healthy limbs—most of whom have both two arms and two legs but who identify as amputees and, therefore, who wish to have some of their healthy limbs surgically severed from their bodies. Correlatively, the logic of one’s expressing ethical disapprobation regarding the amputation of healthy limbs in those with BIID appears to entail the ethical disapprobation of SRS in those with GD seeking SRS. Although extremely rare, it is important to appreciate that there are multiple case reports in the clinical literature in which surgeons have proceeded to amputate the healthy limbs of persons suffering from BIID who have requested limb amputations.[3]

This apparent conceptual parity between GD and BIID is all the more striking in light of recent social movements and recent scholarship that avoid any attribution of “disability” to amputees and others traditionally categorized as being disabled.[4] These social movements erase one of the more plausible ethical objections to limb amputation in BIID, namely that elective amputation in such individuals would result in serious disability. Those, on the other hand, who recognize limb amputation as resulting in a kind of disability see such amputations as being strikingly different from the amputation of breasts, penises, and testicles. The imparity claim in this context is simply that the biological targets of these different amputations are relevantly dissimilar insofar as no functional disability results from the “gender affirming” amputation, say, of a penis and testicles, while there is serious functional disability that results from the amputation of one’s limbs. Furthermore, one has only one biological genital “unit” that might be a target of amputation (although this genital unit might be ambiguous between male and female external genitalia, comprising an intersex condition), while one has, ordinarily, four limbs which might be targets of amputation. The more limbs amputated ceteris paribus, one might argue, the greater the degree of one’s disability. To have all four of one’s limbs amputated, uncontroversially, would result in almost total dependency on others.[5]

The issues that the notion of “disability” introduces in this context are multifaceted and complex. I will mention only two of them. First, the very idea of what constitutes a relevant function presupposed by those who oppose elective limb amputation in those persons with BIID, but who approve of the amputation of one’s breasts or genitals in transgendered persons, appears to be very narrow—as is the notion of “function” that the American Psychiatric Association (APA) appears to endorse in the DSM-5-TR (as was also the case in previous DSM editions). In contrast to a narrow view of function, it seems clear to me that one’s being impaired regarding one’s functioning presupposes that one is a certain kind of thing for which that function is proper. Suppose, for example, that one’s psychology precludes one from marrying and, correlatively, having conjugal relations with someone of the opposite sex. That appears clearly to me, and to many others, to constitute a functional impairment; however, it would not be considered a functional impairment according to the APA. One with, for example, an exclusively homosexual sexual orientation whose sexual orientation precludes that individual from marrying[6] would not be considered, according to the APA, to be functionally impaired. In the broader view of what counts as functional impairment, on the other hand, a man whose penis has been amputated and who cannot have conjugal relations as a result—just as one who had one’s leg amputated precludes one’s walking unassisted—is, thereby, a paradigm case of functional impairment.

Of course, there is a long tradition of thought, most well developed in the Christian tradition (more specifically, most well developed in Roman Catholic moral thought) that argues for it being unethical to amputate any normally functioning body part, considering such amputations—including the amputation of normally functioning breasts and genitals—as forms of self-mutilation.[7] It is not difficult to discern that this ethical prohibition against self-mutilation would be linked conceptually with the natures of human beings and with what is required for human beings to be functioning properly (i.e., functioning in accord with human nature).

II. Lack of Long-Term Data

Second, although SRS and hormonal treatments appear clearly to decrease gender dysphoria significantly in the short run for the great majority of those who undergo these clinical interventions, there is, contrary to widespread belief, no convincing evidence thus far that, in a significant number of those who undergo SRS or hormonal manipulation, gender dysphoria decreases in the long run. The largest population-based matched cohort study thus far that addresses this question found substantially high rates of completed suicides, psychiatric hospitalizations, and suicide attempts in those transgendered persons who underwent SRS or hormonal treatments.[8] For example, Swedish researchers found a suicide rate 19 times (i.e., 1,900%) higher in sex-reassigned transgendered persons than for age- and birth sex-matched controls. For methodological reasons, this study cannot properly be claimed to demonstrate that completed suicide, psychiatric hospitalization, and suicide attempts are a result of transgendered individuals having undergone SRS or hormonal treatments, only that those transgendered individuals who underwent SRS or hormonal treatments did not demonstrate either less long-term gender dysphoria, or a lower completed suicide rate, or less psychiatric hospitalizations, or a lower suicide attempt rate than those transgendered individuals who did not undergo these treatments.

Although an adequate assessment regarding suicide and other forms of self-injurious behavior is essential for those suffering with GD or are otherwise transgendered, in my experience, adequate assessments for suicidality, quite generally considered, are not routinely undertaken. This pervasive problem in the mental health field places many GD patients at significant risk. Simply asking someone, for example, if one is having thoughts of suicide or other forms of self-injury in the context of a psychiatric interview constitutes a woefully inadequate assessment regarding one’s risk for suicide and other forms of self-injury. Even when the “Columbia-Suicide Severity Rating Scale” (C-SSRS) is routinely administered (as is the case, currently, in many mental healthcare systems), it is often administered mechanically and not followed up with the care, the curiosity, or the depth of additional clinical assessment that a “positive” C-SSRS demands.

On the other hand, a registry-based study, also from Sweden, by Branstrom and Pachankis,[9] suggests that an increased amount of time since one’s last SRS procedure was associated with reduced levels of mental health treatment for mood or anxiety disorders—by 8% per year—although these levels were still significantly higher than levels of mental health treatment for these conditions in the general population even 10 years after one’s last SRS procedure. Hormonal treatment alone, however, in that study, did not appear to result in any significant decrease in mental health treatment levels for anxiety or depression in transgendered individuals. However, it is noteworthy that Branstrom and Pachankis’s conclusion has recently been retracted by the American Journal of Psychiatry due to multiple significant statistical irregularities and, correlatively, misshapen inferences derived from their data set.[10] In a similar vein, a recent study by Turban, King, Carswell, and Keurophlian concluded that suicidal ideation is decreased in transgendered adults who, in adolescence, had been treated with “puberty blocking” hormones (i.e., gonadotropin-releasing hormone analogs, GnRHa’s).[11] However, several concerns arise with this study: (1) this study’s sample was nonrepresentative, (2) only one (of nine) measure in the study was statistically significant (i.e., that particular measure regarding suicidal ideation), and (3) the authors barely acknowledged that adolescents with serious psychiatric problems would have been less eligible to receive GnRHa treatment.

III. Special Problems with Informed Consent.

Third, it is important to emphasize that one outcome of all instances of SRS (even among those very small number of people who undergo a “reversal” of their SRS), given the current state of the art, is lifetime sterility. Furthermore, according to the Mayo Clinic, potential complications from hormonal treatments for GD include (with respect to masculinizing hormones): polycythemia (a malignancy of red blood cells), weight gain, sleep apnea, dyslipidemia, hypertension, Type II diabetes mellitus, cardiovascular disease, the worsening of certain underlying psychiatric disorders, gallstones, hyperkalemia (high serum potassium), hypertriglyceridemia, weight gain, deep vein thrombosis, pulmonary embolism (blood clots in the lung’s arteries), elevated liver enzymes (reflecting liver damage), and hyperprolactinemia (an increase in the hormone prolactin, which can interfere with bone development and sexual response, and can lead to gynecomastia—breast enlargement in men). This makes the adequacy of the informed consent process regarding SRS all the more critical.

Difficulties with the informed consent process concerning hormonal treatment and SRS in transgendered persons are of great concern for multiple reasons, including complexities involving obtaining informed consent from minors, difficulties with anyone (but particularly with children and minors) clearly envisioning the outcome of a choice of the magnitude of SRS specifically, and the disproportionately large number of persons with Autistic Spectrum Disorders who seek treatment for GD (a 4-fold increase in children and adolescents compared to those who are neurotypical in some studies) for whom the informed consent process requires significant modification.[12] There are challenges, even under the best of circumstances, in communicating optimally with those with Autistic Spectrum Disorder in light of the peculiar deficits in social communication, social interaction, social-emotional reciprocity (including failure of normal back and forth conversation), and non-verbal communication intrinsic to that disorder. Furthermore, decision-making might be further impaired in light inter alia of the difficulties such individuals have in accessing, sharing, and processing emotions.

Also, there is, in some transgendered persons, a frantic rush to hormonal treatment and SRS due to struggles with “homophobia”—as a result of one’s deep aversion to identifying oneself as homosexual, or to a deep aversion to one’s engaging in perceived homosexual activity—in those transgendered persons who are erotically attracted to persons who share their birth sex. These transgendered individuals are prone to a single-minded push in the direction of gender reassignment so as to confirm these transgendered individuals’ “heterosexual” sexual orientations. Finally, the prevalence of self-injurious behavior in this patient population, in conjunction with the unfounded widespread belief that hormonal treatment and SRS are protective regarding such self-injurious behavior in the long run, provides further impetus to forge ahead with these treatments without attending to the finer points of a comprehensive informed consent process. Medico-legal concerns, not surprisingly, loom large in this arena.

Furthermore, decision-making in this arena, whether or not one is on the autistic spectrum—especially if one’s brain development has not fully matured,[13] as is believed to be the case, according to some investigators, into one’s early 30s—is potentially made more perilous by the cognitive limitations inherent in deliberations concerning what direction one might decide to take regarding one’s future health and well-being. Arguably, sometimes the circumstances in one’s future are so far removed from one’s current circumstances that one’s being in these future states of affairs is psychologically impossible to imagine. In other instances, the stability of one’s desires cannot reasonably be predicted—something to which anyone who has interacted with children and teenagers for any length of time can attest.

This does not mean, of course, that there are no medical decisions with lifelong ramifications that even a relatively young child might be able to make. Rather, the difficulty is with those life circumstances that are radically life-altering, that foresight can only dimly illuminate, and that are driven by developmentally unstable desires, as they are in a great many individuals—especially in children and adolescents—as one’s life unfolds and as one matures. (The discussion below regarding “desistance rates” further illuminates this critically important point.) There are, as a result, substantial dangers in the downward turn in guidelines regarding the age at which medical “gender affirming” treatments are believed to be considered to be clinically appropriate. For example, perhaps the world’s most influential body advocating for “gender affirming” procedures, the World Professional Association for Transgender Health (WPATH)—in preparation for its latest “Standards of Care for the Health of Transgender and Gender Diverse People, Version 8”[14] (hereafter, “Standards of Care”)—had been considering a downward departure in the ages at which minors can consent to gender affirming medical (hormonal and surgical) procedures specifying age 14-years as the proposed threshold for decisions regarding hormonal treatment and as young as 15-years for female breast removal, 16-years for breast augmentation in males, 17-years for removal of the uterus (hysterectomy) and for surgically fashioning a vagina in males (vaginoplasty), with 17-years also for castration, and 18-years for surgically fashioning a penis in females.

Oddly, no significant ethical reflection was undertaken by the WPATH committee in a manner that ultimately made it into the final version of WPATH’s “Standards of Care.” In the process of WPATH’s deliberations, however, it was specifically noted—to WPATH’s credit—that age was only one of multiple other relevant factors that should be taken into account when considering whether a transgendered individual is an appropriate candidate for SRS. These other relevant factors included emotional maturity, longstanding gender dysphoria, and a psychological evaluation. WPATH also noted that parental consent was an additional relevant factor, although WPATH additionally considered a troubling alternative to parental consent, viz. there being no requirement for parental consent, so long as court authorization was secured.

This latter alternative is the focus of an article by Federica Vergani who writes,

Transgender children who wish to begin hormone suppression therapy are required to obtain their parents’ consent. . . . [However] children should be able to access such treatments with court authorization in situations where their parents do not consent to the treatment. Gender identity is protected under the fundamental right to liberty because it is part of the person’s autonomy of self. Additionally, the United States Supreme Court’s Fourteenth Amendment jurisprudence indicates that the right to make decisions pertaining to one’s sexuality are within the ambit of the right to privacy. For this reason, children have a right to privacy that includes the ability to decide whether to take hormone suppressants. The State’s interests in restricting this privacy right are not significant so as to render the parental consent requirement valid. Therefore, States must provide children with a judicial bypass procedure whereby they can access hormone suppression treatments without parental consent.[15]

What Vergani fails to appreciate, besides the surface level moral repugnancy of her view insofar as it contravenes parents’ moral responsibility to raise and educate their children in accord with the dictates of natural law, are some of the unforeseen consequences of the principles she invokes in order to justify her position. One such unforeseen consequence involves how these principles bear on childhood sexual activity—amongst minors themselves, or amongst adults and minors involving what is sometimes euphemistically referred to as “intergenerational sexual activity.”[16] Is not sexual activity a privacy right, according to Vergani’s interpretation of the 14^th Amendment? Is not sexual activity that is not forced “protected under the fundamental right to liberty because it is part of the person’s autonomy of self”? Are the “State’s interests in restricting this privacy right” so “significant so as to render the parental consent requirement valid” or must States “provide children with a judicial bypass procedure whereby they can” access sexual activity with other minors or adults “without parental consent”?[17]

Startlingly, in the end, WPATH dropped any age threshold for clinically proper decisions regarding hormonal or surgical treatment of transgendered individuals.[18] As succinctly stated by Jennifer Block,

New clinical guidelines that will influence the care of transgender people in the US and internationally have removed recommendations on the minimum age for treatment, including hormones and surgery, and left decisions in the hands of clinicians. . . . in part due to the “exponential growth in adolescent referral rates.” Health system based studies previously showed referral rates under 0.1%, while newer surveys measuring “transgender” identity find prevalence of 1.2% to 2.7% among children and adolescents and “gender diverse” identities as high as 9%.[19]

IV. Importance of High Desistance Rates

Fourth, the desistance rates (i.e., the rates at which persons with GD at some earlier time resolve their GD and revert to identifying with their natal sex at some later time) in children with GD ranges from percentages in the 60s to percentages in the 90s, with every single one of the over 10 studies that have examined this question finding that a majority of GD children eventually desist.[20] This means that, in the clear majority—and, in some studies, the overwhelming majority—of cases, children with GD, with or without treatment, do not become adults with GD. There does seem to be a greater probability of those children with more persistent and prominent GD to continue on to adult GD, and clearly fewer adolescents desist than do children. However, even in those minors with longstanding and intense GD there is a small but significant percentage of children who desist. We have, therefore, no way of accurately predicting, for any given individual case, which GD child will, and which GD child will not, go on to be gender dysphoric adults. Some of these studies have been criticized for allowing into their samples a minority of “gender non-conforming” children (e.g., “tomboys”), rather than children with GD. (This is clearly not the case, however, with Singh’s study.)[21] However, even if this were so, these studies still reflect noteworthy percentages of desistance rates in GD children.

These figures are startling and should give pause to everyone in this discussion. To rush into delivering “gender affirming care” with hormonal treatments or surgery in children or adolescents who would have eventually desisted without treatment risks two critical outcomes: first, “detransitioning,” with all of its attendant risks and, second, confirming persons in gender identities that they would not have embraced but for the “gender affirming care” that they have received. A significant minority of persons regret having undergone SRS or have begun hormonal treatment and have asked for surgical reversion to their (male or female) birth sex or have discontinued hormonal treatments. However, the majority of those who have undergone SRS, when asked, clearly do not express any such regrets—although, the evidence does not yet support that their non-regret is predictably merely a function of their significantly experiencing less gender dysphoria.

V. Need for Thorough and Subtle Assessments

Fifth, multiple psychiatric conditions mimic typical transgender conditions, or have gender dysphoria as an epiphenomenon, including psychotic, mood, personality (including Borderline Personality Disorder), and, perhaps the most underappreciated of all GD mimics, dissociative disorders. Discovering the source of one’s gender-relevant emotions, therefore, can be very complex and confusing, even for psychiatrists, requiring subtle diagnostic skills and extended evaluations, including input from collateral sources of information. Finally, of course, simple “gender nonconformity” (as alluded to earlier) can be, and has been, mistaken for GD.

According to Joost à Campo, Henk Nijman, H. Merckelbach, and Catharine Evers,

In the Netherlands, it is considered good medical practice to offer patients with gender identity disorder the option to undergo hormonal and surgical sex reassignment therapy. A liberalization of treatment guidelines now allows for such treatment to be started at puberty or prepuberty. The question arises as to what extent gender identity disorder can be reliably distinguished from a cross-gender identification that is secondary to other psychiatric disorders. . . . The authors sent survey questionnaires to 382 board-certified Dutch psychiatrists regarding their experiences with diagnosing and treating patients with gender identity disorder. . . . One hundred eighty-six psychiatrists responded to the survey. These respondents reported on 584 patients with cross-gender identification. In 225 patients (39%), gender identity disorder was regarded as the primary diagnosis. For the remaining 359 patients (61%), cross-gender identification was comorbid with other psychiatric disorders. In 270 (75%) of these 359 patients, cross-gender identification was interpreted as an epiphenomenon of other psychiatric illnesses, notably personality, mood, dissociative, and psychotic disorders.[22]

It is important to highlight the manner in which advocates of “gender affirming” treatments routinely elide complexities inherent in the assessment process of those who report gender-related concerns. WPATH, for example, in its Version 8 “Standards of Care” guideline, recommends that clinical evaluators “undertake a comprehensive biopsychosocial assessment of adolescents.” However, the details of any such evaluation are not spelled out with the required degree of specificity or with a keen appreciation for the range of developmental, psychodynamic, sociocultural, or psychopathological determinants that often motivate gender concerns—especially in minors.

Adolescence is an especially troubling developmental period in this regard, where multiple identities are “tried on” as a matter of course. Children, of course, are very imaginative. One would expect their identities, at various times, to be a function of their imaginative capacity rather than a function of their core identities. Similarly, adults with Borderline Personality Disorders have, as a feature intrinsic to their very serious personality disorder, a deep and pervasive problem regarding the stability of their identities, and they often have a tendency to dissociate when stressed. Correlatively, some people with dissociative disorders feel “disconnected” from their bodies—experiencing, at times, that their bodies are not their own. Furthermore, rumination, brooding, and somatic concerns are not uncommon in clinically depressed individuals and sometimes lead to confusion regarding one’s sex or gender. In addition, some people who express gender concerns have peculiar paraphilias (i.e., intense and persistent sexual interests in something other than genital stimulation or preparatory fondling with physically mature, phenotypically normal, consenting sex partners) such as autogynephilia, in which fantasizing about oneself as being a member of the opposite sex is sexually arousing and which, thereby, motivates one’s request for “gender affirming” treatments. Also, some persons with Body Dysmorphic Disorder focus on perceived defects or flaws involving their genitals and can, therefore, appear to be gender dysphoric. In addition, some of those who suffer from Obsessive-Compulsive Disorder have reported intrusive thoughts that their sex is other than their natal sex. And, of course, any psychiatrist who has been in practice long enough will have met a schizophrenic or other psychotic individual who has clearly incorporated a gender discordant delusion in his or her delusional system.

VI. A Deep Religiously-Based Objection

Sixth, perhaps the most troubling aspect of contemporary gender ideology according to many religious persons, particularly Christians, is that this ideology is judged to be deeply morally perverse at its core primarily because of its sanctioning supplanting God’s creative activity with one’s own and, as a result, undertaking a reordering of creation, or, more specifically, replacing God’s original order with one’s own disorder. The claim is not simply that this ideology fails to recognize two distinct sexes, as was God’s original intention in the creation accounts of Genesis 1 and 2, or simply that it is absurd to claim that one actually is who or what one identifies as being, in accord with some very general principle regarding the manner in which one’s mere subjectivity transform what one is merely by way of identifying oneself in one way rather than another. Rather, the perceived repulsiveness of this ideology lies most deeply in its ascribing to human beings a “creative” power that displaces God’s creation and supplants it with one’s own (disordered) “creations.” In this manner, contemporary gender ideology’s transformative end, in its more extreme manifestations, can be thought to be relevantly similar to a sociopolitical realization of H.G. Wells’ Island of Dr. Moreau in which the mad scientist, Dr. Moreau, “creates,” by way of vivisection, a menagerie of twisted hybrid creatures with human traits. Importantly, the horror one experiences when first exposed to the denizens of Dr. Moreau’s Island, initially, involves an emotional response to his grotesque creations themselves. A little deeper below the surface, however, one locates a much greater horror, namely, Dr. Moreau himself, who not only demonstrates how ghoulish creation could have been (or could be)—if left in the hands of a less than wise, finite creaturely “creator” with severely limited knowledge—but how much more horrifying than his creation that the creaturely “creator” himself is. It is no wonder that Wells famously, and insightfully, referred to his novel as “an exercise in youthful blasphemy.”[23]

The following hypothetical response by defenders of contemporary gender ideology would not be unexpected:

We are not disfiguring or mutilating or disordering or creating anything but, rather, we are “setting things aright.” Transgender men (i.e., adult biological females who identify as men) are men, and transgender women (i.e., adult biological males who identify as women) are women. Civilization has, up until this point, largely gotten it wrong. It is not how one appears that makes one a man or a woman (or something in between, or beyond), but how one thinks of oneself. Appearance and reality come apart here, as in many other now widely acknowledged contexts (including the world’s not appearing round and not appearing to be moving by those on its surface). What we are doing is looking beyond mere appearances and what we are trying to do is to mend the mismatch, to provide as best as we can a body that fits one’s mind. In this manner we are assisting in the bringing about of properly ordered creation—just as surgeons do when fixing structural defects. We are no more misguided, foolish “creaturely creators” than them but, rather, like them, we are healers. It is you who destroy by depriving these deeply suffering persons of relief, peace, and fulfillment, by depriving them of their proper bodies and, thereby, amplify their suffering, depriving them of contentment, fulfillment, and peace.

Attempts to point out that those with female bodies are, by virtue of their biology, female, and those with male bodies are, by virtue of their biology, male, and that if one would really like to heal transgendered individuals, then one ought invest one’s time and resources in finding ways of healing the minds of those who think otherwise, are met with stiff resistance. The response is frequently that biological sex itself is a social construction. There simply are no males or females, objectively speaking; rather, the categories of “male” and “female” are subjectively constituted—very much like race, ethnicity, currency (money), and countries. One of the most important aspects of this claim, in my experience, is the recruitment intersex conditions to defend the claim that sexed bodies—not merely genders—are social constructions through and through.

Now, I believe that there are multiple adequate ways of disposing of this claim. I will briefly mention only one. One can, of course, reject what I am about to say—just as one can reject any claim—but one does so at very great expense, indeed. Suppose that intersex conditions (i.e., understood broadly as conditions in which both male and female sexual characteristics occur in a single individual) demonstrate that there no objective sexes. As one such argument states, intersex conditions make it arbitrary whether any specific intersex person is male or female. This is because intersex conditions make clear to us that there is a continuity of possible anatomical variations between what we typically call biological males and what we typically call biological females. In other words, the chasm between what we canonically refer to as a male and what we canonically refer to as a female is bridged by a hypothesized smooth series of intersex intermediaries. If there were, therefore, only two sexes, then what constitutes those two sexes would require a cut-off point on that hypothesized continuum, on one side of which would be males and on the other side of which would be females. However, any such cut-off point would be arbitrary—a mere expression of cultural or sociopolitical or personal preference—rather than based on an objective, nonarbitrary reasoned distinction between objectively biologically constituted males and females. Hence, the argument goes, because no such cut-off point can be rationally specified, there simply are no objectively constituted males or females, but only what we subjectively, socially construct as males and females.[24]

Well, if that argument is a good one, and if standard accounts of evolutionary theory are true, then not only are there no objectively constituted males and females, but there are also no objectively constituted human beings, dogs, fish, insects, plants, algae, wombats, thrips, etc. There are, in fact, not even any molecules, or any composite thing, since, in the domain of composite objects more broadly, there is also a hypothesized continuous, smooth line of development between the inanimate world of elementary particles and all seemingly composite things, including what we call human beings, and it is simply arbitrary where one composite object ends and another starts.

VII. Controversies Concerning the Existence of Rapid-Onset of Gender Dysphoria

Seventh, some adolescents and young adults who identify with a gender that is discordant with their birth sex appear rapidly to develop GD and, correlatively, rapidly adopt a cross-gender identity, in some of these cases as a result of a GD and transgender identity contagion. These individuals appear to have no discernible prior gender-related concerns. This Rapid Onset Gender Dysphoria (ROGD) was recently investigated in a study by Lisa Littman.[25] In large part, methodological limitations with Littman’s study precipitated a revision of her study. These limitations preclude one’s wholly embracing the extent of ROGD reported by the parents involved in Littman’s study. The fact that ROGD occurs, however, in some adolescents and young adults cannot be reasonably disputed.

It would be truly remarkable if some mechanism of psychological contagion did not exist in the domain of gender identity, as it clearly does in many other psychological domains. Psychological contagions have, for example, been described in the context of violence (including “copycat” suicides and homicides); dissociation; delusions (in what used to be called Shared Delusional Disorder); the Strasbourg, Alsace “dancing plague” of 1518; the Tanganyika “laughter epidemic” of 1962; vicarious dramatization in the context of Posttraumatic Stress Disorder; and reported cases of depressive and obsessive-compulsive symptoms.[26]

VIII. The Recent Depathologizing of Gender Dysphoria

Eighth, just as, for the first time in DSM history, the Diagnostic and Statistical Manual of Mental Disorders, 5^th Edition (DSM-5, 2013) authors no longer consider pedophilia to be a psychiatric disorder,[27] DSM-5 authors also, for the first time in DSM history, do not consider GD to be a psychiatric disorder. As a result, there may be a greater tendency for clinicians not to thoroughly investigate GD and transgender identification claims by patients in an attempt to uncover its psychopathological roots, in spite of substantially high risks in the GD and transgender patient population for engaging in self-injurious behaviors, including suicide attempts and completed suicide (as noted above).

Just as the claim that pedophilia—contrary to what is stated, with a straight face, by the APA—is not profoundly psychopathological is false on its face, even if a pedophile is not functionally impaired (in the APA’s narrow sense) in a manner that one experiences interpersonal difficulty, is markedly distressed, or does not act on one’s pedophilic impulses, the claim that one’s transgender identification dictates what one is, is also false on its face. The general principle that one is who or what one identifies oneself to be is more than merely false—it is patently absurd. To think otherwise, in the absence of special pleading, is to eliminate an entire category of psychopathological symptom, namely, the category of delusion (at least those delusions concerning who one is). Furthermore, generalizing the principle on which contemporary transgender ideology is based would result in our acknowledging people who identify with an age or race or height or weight or species different than they are, to be that age, race, height, weight, or species. But that is patently absurd.

IX. The Role of Genetics and Environment?

Ninth, a fundamental axiom of biology is that phenotype (i.e., roughly, an organism’s observable characteristics) = genotype (an organism’s genetic makeup) + environment. Hence, it stands to reason that GD (or transgender identification)—like any other human trait—results, in part, from some degree of genetic contribution in addition to some degree of environmental contribution. There is, however—as is also the case with bisexuality or homosexuality—no compelling evidence that GD (or transgender identification) is either genetically determined or strongly genetically loaded, with heritability studies suggesting polygenetic vulnerability and with one study finding 67% (for males) and 77% (for females) discordance rates for GD in monozygotic twins.[28]

X. The Role of Psychotherapeutic Treatment

Tenth, although there are multiple clinical case studies reporting positive outcomes of individual psychotherapy with transgender patients—where a positive outcome involves a change to a gender identity that is consistent with one’s biological sex—there is not one adequately designed randomized controlled clinical trial of psychotherapy for transgender persons or persons with gender dysphoria more broadly, which has investigated the effectiveness of psychotherapy for altering gender identification or GD. In spite of this, many clinicians perceive that the only viable clinical intervention for members of this patient population with extreme GD who strongly exhibit longstanding cross-gender identification is hormonal treatment or SRS. Of course, case studies by themselves cannot establish that there is any such viable treatment of this sort. What they do establish, however, is that it would be imprudent to foreclose the clinical possibility of altering gender identification or significantly attenuating, or ameliorating, GD with psychotherapeutic techniques and that gender identification and GD can change during a course of psychotherapy, whether or not the psychotherapy itself is the vehicle for that change.[29]

Interestingly, as noted by Block, WPATH asserts “that the quality and quantity of the evidence on effectiveness of treatments in adolescents renders a systematic review ‘not possible’ but at the same time,” they claim, “the evidence ‘indicates a general improvement in the lives of transgender adolescents’ who receive medical treatment.’”[30] It is not explained how this is coherent or, even if coherent, how this is helpful to an adolescent who is faced with making a decision regarding whether or not to undergo transgender medical procedures. With not even one adequate randomized controlled study that evaluates psychotherapeutic interventions with transgendered persons in any age range, decision-making in this domain becomes further complicated insofar as the range of appropriate choices in this arena remains unclear. Under these circumstances—with no clarity regarding the options guiding treatment choice—how is any transgendered individual to know how best to proceed?

References

[1] Gender dysphoria is a condition that can be found in the American Psychiatric Association’s compendium of psychiatric nosology, the DSM-5-TR (Diagnostic and Statistical Manual of Mental Disorders, 5^th Edition, Text Revision, Washington, DC: American Psychiatric Association, 2022). According to the DSM-5-TR, gender dysphoria requires a marked incongruence between one’s experienced or expressed gender and one’s assigned gender, of at least six months duration, in addition to six of eight possible symptoms, including in that list of eight possible symptoms a strong dislike of one’s sexual anatomy and a strong desire for the primary or secondary sex characteristics that match one’s experienced gender.

[2] There is no consensus regarding what it means to be “transgendered.” Broadly, transgendered individuals are those whose gender identity (e.g., whether they identify as males or as females) does not align with their biological sex. However, that characterization would categorize those individuals who have “non-binary” gender identities as being transgendered, in spite of some of those individuals not being comfortable with a “transgendered” designation, since they deny being “gendered” at all. Furthermore, not all people with transgender identifications fulfill what the DSM-5-TR calls “gender dysphoria”—the only official condition in the DSM that is not considered to be a disorder, in spite of its being catalogued in American psychiatry’s compendium of mental disorders. One might be DSM-5-TR gender dysphoric, but not have a transgender identification; on the other hand, one might have a transgender identification and not suffer from DSM-5-TR gender dysphoria (although, of course, one might both have a transgender identification and fulfill DSM-5-TR diagnostic criteria for gender dysphoria), hence the distinction in this essay between those with gender dysphoria and those with transgender identification.

[3] For discussions concerning psychiatric disorders of somatic integrity, including data regarding amputation as a treatment for BIID, see Glenn Stanton, “Woman Demands Doctors Sever Her Spinal Cord to Align Body to Mind, ‘Same as a Transsexual Man,’” The Federalist, April 4, 2017, https://thefederalist.com/2017/04/04/woman-demands-doctors-sever-spinal-cord-fit-body-mind-transsexual-man/; Carl Elliott, “A New Way to be Mad,” The Atlantic, December 2000, https://www.theatlantic.com/magazine/archive/2000/12/a-new-way-to-be-mad/304671; Rianne Blom, Raoul Hennekam, and Damiaan Denys, “Body Integrity Identity Disorder,” PLOS One 7, no. 4 (April 13, 2012): e34702, https://doi.org/10.1371/journal.pone.0034702; and Anne A. Lawrence, “Clinical and Theoretical Parallels Between Desire for Limb Amputation and Gender Identity Disorder,” Archives of Sexual Behavior 35, no. 3 (June 2006): 263–78.

[4] For a nuanced discussion of this issue, see, Emily Heavey, “The Multiple Meanings of ‘Disability’ in Interviews with Amputees,” Communication and Medicine 10, no. 2 (2013): 129–39.

[5] There are, of course, complexities that arise in this, as in any other, context. Prince Randian, “The Human Torso,” who appeared in Thomas Browning’s justifiably famous, jarring 1932 film Freaks, was born with no limbs, yet was able to light and smoke a cigarette (as he demonstrated in that remarkable film). Correlatively, although Bonnie Consolo was born without arms, she exhibits, in the astonishing 1975 film A Day in the Life of Bonnie Consolo, quite remarkable physical abilities (including washing dishes, eating with utensils, driving a motor vehicle, and killing a fly in midair) using only her feet. It is noteworthy that both Prince Randian and Bonnie Consolo were born with missing limbs, and that nervous system plasticity during development gives those with congenital missing limbs a significant advantage regarding functioning with missing limbs in comparison to those who might later (as, for example, an adult) undergo limb amputation.

[6] I am using the term “marrying” and its cognates in a manner that reflects its original meaning rather than the contractual, fictive conceptualization of what it means to marry that is current.

[7] For a nuanced discussion of the ethics surrounding the act of amputation, see Nicanor Pier Giorgio Austriaco, “Is Self-Amputation for Survival Morally Justifiable?” The Linacre Quarterly 89, no. 2 (2022): 206–11, https://doi.org/10.1177/00243639221084766.

[8] Cecilia Dhejne, Paul Lichtenstien, Marcus Boman et al., “Long-Term Follow-Up of Transsexual Persons Undergoing Sexual Reassignment Surgery: Cohort Study in Sweden,” PLOS ONE 6, no. 2 (February 22, 2011): e16885, https://doi.org/10.1371/journal.pone.0016885.

[9] Richard Branstrom and John Pachankis, “Reduction in Mental Health Treatment Utilization Among Transgender Individuals After Gender-Affirming Surgeries: A Total Population Study,” American Journal of Psychiatry 177, no. 8 (August 2020): 727–34, https://doi.org/10.1176/appi.ajp.2019.19010080.

[10] Branstrom and Pachankis concede their critics’ main points by replying, “Our conclusion based on the findings at hand in the article, which used neither a prospective cohort design nor a randomized controlled trial design, was too strong” (Branstrom and Pachankis, “Reduction in Mental Health Treatment,” 772). For representative critiques, see Andre Van Mol, Michael Laidlaw, Miriam Grossman, and Paul McHugh, “Letters to the Editor: ‘Gender-Affirmation Surgery Conclusion Lacks Evidence,’” American Journal of Psychiatry 177, no. 8 (August 2020): 765–66, https://doi.org/10.1176/appi.ajp.2020.19111130; and David Curtis, “Study of Transgender Patients: Conclusions Are Not Supported by Findings,” American Journal of Psychiatry 177, no. 8 (August 2020): 766, https://doi.org/10.1176/appi.ajp.2020.19111131.

[11] Jack Turban, Dana King, Jeremi Carswell, and Alex Keurophlian, “Pubertal Suppression for Transgender Youth and Risk of Suicidal Ideation,” Pediatrics 145, no. 2 (2020): e20191725, https://doi.org/10.1542/peds.2019-1725. For a concise yet comprehensive critique of Turban et al., see Michael Biggs, “Puberty Blockers and Suicidality in Adolescents Suffering from Gender Dysphoria,” Archives of Sexual Behavior 49 (2020): 2227–29, https://doi.org/10.1007/s10508-020-01743-6.

[12] See, for example, Anna I.R. van der Miesen, Annelou L.C. de Vries, Thomas Steensma, and Catharina Hartman, “Autistic Symptoms in Children and Adolescents with Gender Dysphoria,” Journal of Autism and Developmental Disorders 48, no. 5 (2018): 1537–48.

[13] Contemporary views of brain development have extended the period of adolescence, biologically speaking, into the mid to late 20’s or even the early 30’s. See, for example, Mariam Arain, Maliha Haque, Lina Johal et al., “Maturation of the Adolescent Brain,” Neuropsychiatric Disease and Treatment 9 (2013): 449–61, https://doi.org/10.2147/NDT.S39776; Catherine Lebel and Christian Beaulieu, “Longitudinal Development of Human Brain Wiring Continues from Childhood into Adulthood,” The Journal of Neuroscience 31, no. 30 (2011): 10937–47, https://doi.org/10.1523/JNEUROSCI.5302-10.2011; and Sarah Johnson, Robert Blum, and Jay Giedd, “Adolescent Maturity and the Brain: The Promises and Pitfalls of Neuroscience Research in Adolescent Health Policy,” Adolescent Health 45, no. 3 (September 2009): 216–21.

[14] E. Coleman, A. E. Radix, W. P. Bouman et al., “Standards of Care for the Health of Transgender and Gender Diverse People, Version 8,” International Journal of Transgender Health (September 15, 2022): S1–S259, https://doi.org/10.1080/26895269.2022.2100644.

[15] Federica Vergani, “Why Transgender Children Should Have the Right to Block Their Own Puberty with Court Authorization,” FIU Law Review Article 13, no. 4 (2019): 903, https://ecollections.law.fiu.edu/lawreview/vol13/iss4/16 (emphasis added).

[16] An immediate objection to this application of Vergani’s principles regarding gender affirming medical treatment to sexual activity involving minors is likely to go something like this: “Of course, little children should not be able to have sexual intercourse with adults. That is child abuse.” Well, one might reply, “Tu quoque,” i.e., one reply is that “child abuse” of a different, but related, sort (involving, for example, genital mutilation) is precisely what is being advocated by “gender affirming” surgical procedure advocates. More subtly and creatively, it should come as no surprise that not all sexual activity involves sexual intercourse. If a child’s parents—or the court—should sanction child sexual activity, short of sexual intercourse, based on which of Vergani’s principles could such sexual activity be prohibited?

[17] Vergani, “Why Transgender Children Should Have the Right,” 903.

[18] See, for example, Coleman et al. “Standards of Care,” 259.

[19] Jennifer Block, “US Transgender Health Guidelines Leave Age of Treatment Initiation Open to Clinical Judgment,” BMJ 378 (2022): 1, https://doi.org/10.1136/bmj.o2303.

[20] For a rate of desistance at the lower end of this range, see Thomas Steensma, Jenifer McGuire, Baudewijntje Kreukels et al., “Factors Associated with Desistance and Persistence of Childhood Gender Dysphoria: A Quantitative Follow-Up Study,” Journal of the American Academy of Child Adolescent Psychiatry 52, no. 6 (June 2013): 582–90, https://doi.org/10.1016/j.jaac.2013.03.016. For a study that is at the higher end of this range, see Devita Singh, “A Follow-Up Study of Boys with Gender Identity Disorder,” (PhD diss., University of Toronto, 2012), https://tspace.library.utoronto.ca/bitstream/1807/34926/1/Singh_Devita_201211_PhD_Thesis.pdf. An adapted version of this has been published as Devita Singh, Susan Bradley, and Kenneth Zucker, “A Follow-Up Study of Boys with Gender Identity Disorder,” Frontiers in Psychiatry 12 (2021): https://doi.org/10.3389/fpsyt.2021.632784.

[21] Singh, Bradley, and Zucker, “A Follow-Up Study of Boys with Gender Identity Disorder.”

[22] See, for example, Joost a Campo, Henk Nijman, Harald Merckelvach, and Catharine Evers, “Psychiatric Comorbidity of Gender Identity Disorders: A Survey Among Dutch Psychiatrists,” American Journal of Psychiatry 160, no. 7 (2003): 1332, https://doi.org/10.1176/appi.ajp.160.7.1332. Regarding dissociation in those with transgender identities, see Christopher H. Rosik, “Opposite-Gender Identity States in Dissociative Identity Disorder: Psychodynamic Insights into a Subset of Same-Sex Behavior and Attractions,” Journal of Psychology and Christianity 31, no. 3 (Fall 2012): 278–84, link.gale.com/apps/doc/A342175861/AONE?u=anon~62b5232e&sid=googleScholar&xid=8ee79330.

[23] See, H. G. Wells’ introduction to The Scientific Romances of H. G. Wells (1933), reprinted in Patrick Parrinder and Robert M. Philmus, eds. H. G. Wells’s Literary Criticism (Totowa, NJ: Barnes & Noble Books, 1980), 243.

[24] A similar argument is widely used in the scholarly arena regarding biological race. There are no biologically objective racial groups, it is claimed, because of the observed, relatively smooth biological continuity—with respect, say, to bone structure, skin color, genetic endowment, and other biological variables—between all human beings. See, for example, Alan Templeton, “Biological Races in Humans,” Studies in History and Philosophy of Science Part C: Studies in History and Philosophy of Biological and Biomedical Sciences 44, no. 3 (September 2013): 262–71, https://doi.org/10.1016/j.shpsc.2013.04.010; and Lisa Gannett, “The Biological Reification of Race,” British Journal for Philosophy of Science 55, no. 2 (June 2004): 323–45.

[25] See Lisa Littman, “Parents Reports of Adolescents and Young Adults Perceived to Show Signs of a Rapid Onset of Gender Dysphoria,” PLOS ONE 13, no. 8 (2018): e0202330, https://doi.org/10.1371/journal.pone.0202330.

[26] Cf. Danny Horesh, Ilanit Hasson-Ohayon, and Anna Harwood-Gross, “The Contagion of Psychopathology across Different Psychiatric Disorders: A Comparative Theoretical Analysis,” Brain Sciences 12, no. 1 (2022): 67, https://doi.org/10.3390/brainsci12010067.

[27] For a detailed account of the American Psychiatric Association’s relatively recently decision to no longer recognize Pedophilia as a mental disorder, see A. A. Howsepian, “Psychiatry’s Dysphoric Turn: Psychophysical Dysmorphia, Transgender Euphoria, and the Rise of Pedophilia,” Christian Bioethics 25, no. 1 (April 2019): 41–68, https://doi.org/10.1093/cb/cby018; and A. A. Howsepian, “American Psychiatry’s Retreat from Reality,” Ethics and Medicine 34, no. 3 (Fall 2018): 153–61.

[28] Cf. Milton Diamond, “Transsexuality Among Twins: Identity Concordance, Transition, Rearing, and Orientation,” International Journal of Transgenderism 14, no. 1 (May 2013): 24–38.

[29] For a representative example of the psychoanalytic treatment of these patients, see Robert Withers, “The Seventh Penis: Towards Effective Psychoanalytic Work with Pre-Surgical Transsexuals,” Analytic Psychology 60, no. 3 (2015): 390–412, https://doi.org/10.1111/1468-5922.12157. This article was subsequently withdrawn in 2021 by the author and journal’s editors due to a consent issue with the publication.

[30] Block, “US Transgender Health Guidelines,” 1.

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