Bioethics @ TIU

Inner Sense and Gender Dysphoria

Posted May 16th, 2017 by Mark McQuain

Steve Phillips posted on “Caring for people with gender dysphoria” almost one year ago. In his post, he referenced a talk at a previous CBHD Summer Conference by Prof. Robert George, where Dr. George posited that the concept that the belief that one’s gender is based one’s innate or inner sense rather than one’s biological/physical sex is rooted in the Gnostic idea that human beings consist of a personal mind that lives in a non-personal body and that this stands in contrast to the longstanding Christian understanding of unity of non-material soul/spirit and material body making up the whole person. I did not attend that talk but offer a recent paper by Dr. George which covers the same ground as backdrop to this post.

The reason for the discussion of Gnosticism related to an earlier point in that same blog referencing the opinion of Dr. Paul McHugh, retired psychiatrist at Johns Hopkins University, who has over the past few years published comments arguing that gender dysphoria is a result of disordered thinking, that is, a mental disorder, requiring treatment, not surgery to complete a gender transition. Dr. McHugh has made much of the fact that Johns Hopkins, despite being an early leader in gender transition surgery, decided very early on that gender transition surgery was not sufficiently efficacious and discontinued the practice.

What a difference a year can make. Johns Hopkins has recently decided to resume what they are calling gender-affirming surgery and specifically point out that when “individuals associated with Johns Hopkins exercise the right of expression, they do not speak on behalf of the institution.”

Johns Hopkins is not alone. A very recent Perspective in the New England Journal of Medicine called “The Future of Transgender Coverage” by Kellan Baker commented that there has been “a rapid increase in insurance coverage for health care services related to gender transition.” Baker offered three reasons to account for this increase: “a growing expert consensus on the medical necessity of gender transition, new legal interpretations prohibiting insurance discrimination against transgender people, and mounting evidence that transgender-inclusive coverage is cost-effective.”

For the sake of the remainder of this blog entry, I want to focus on the first claim: Is there a growing expert consensus on the medical necessity of gender transition?

Gender dysphoria is the term used in the Diagnostic and Statistical Manual of Mental Disorders to describe the clinically significant stress that can occur in a transgender person, one who experiences a discrepancy between one’s innate sense of gender identity and one’s birth sex. Baker says the current standard of care for treating gender dysphoria is gender transition, “which may include mental health counseling, hormone therapy, and reconstructive surgeries affecting primary and secondary sex characteristics.” The source provided for the standard of care claim is a 2012 article in the International Journal of Transgenderism (see here for abstract link – full article requires subscription). Baker supported the growing expert consensus claim by providing a list maintained by Lambda Legal of several major US medical associations consensus statements insisting on health insurance coverage in general for treatment of gender dysphoria, a smaller portion specifically stipulating that coverage include gender transition.

What data is being used to determine whether gender transition is medically necessary to treat gender dysphoria? Available research articles or meta-analyses of these research articles on the long-term outcomes of gender transition is actually less definitive. Most studies are too small to have statistical power, not surprising given the small number of transgender people. Another problem with most studies is lack of a control group. The ideal control group would be a group of transgender people who requested but did not receive gender transition. A third problem is the lack of bias-limiting randomization (though how could one ever ethically design a study where sex-reassignment was done randomly to some patients but not to others?) A summary of the recent research and meta-analysis may be found in a 2016 review article by Lawrence Mayer and Paul McHugh in “Sexuality and Gender” in The New Atlantis (see pages 108-113). Mayer and McHugh conclude their summary by stating they remain skeptical of the efficacy of gender transition in treating gender dysphoria, which has resulted in largely negative and some frankly ad hominem attacks. I was surprised by that response, as the summary includes the meta-analysis by Mayo Clinic researchers Murad et. al., which was arguably pro gender transition regarding self-reported measures reporting some improvement in gender dysphoria, and the large study by Dhejne and colleagues at the Karolinska Institute and Gothenburg University, though showing high suicide rates in sex-reassigned persons (though not suggesting the high suicide rate was caused by the gender transition surgery), went so far as to comment that “things might have been even worse without sex reassignment”. Their study specifically did not address the question of whether gender reassignment alters gender dysphoria.

After conducting my own non-scientific survey of readily available scholarly articles related to gender transition for adult gender dysphoria published since 2016, most of which consisted of small sample, non-randomized, mostly non-controlled studies, I am willing to concede that the majority do state that gender transition reduces gender dysphoria.

But if the gold standard for gender is an individual’s inner sense regardless of that individual’s biological sex (or any other physical/material trait), what objective measure may a researcher reliably use to determine the effect of physical gender transition on gender and gender dysphoria? Per Dr. George (emphasis his):

What is a pre-operative “male-to-female” transgender individual saying when he says he’s “really a woman” and desires surgery to confirm that fact? He’s not saying his sex is female; that’s obviously false. Nor is he saying that his gender is “woman” or “feminine,” even if we grant that gender is partly or wholly a matter of self-presentation and social presence. It is clearly false to say that this biological male is already perceived as a woman. He wants to be perceived this way. Yet the pre-operative claim that he is “really a woman” is the premise of his plea for surgery. So it has to be prior. What, then, does it refer to? The answer cannot be his inner sense. For that would still have to be an inner sense of something—but there seems to be no “something” for it to be the sense of.

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