Noninvasive prenatal testing and sex-selection abortion

By Steve Phillips

The National Health Service in Great Britain has decided to implement the use of noninvasive prenatal testing (NIPT) and that has raised some concerns. It would seem natural for there to be concern about this test used to detect prenatal genetic conditions such as Down syndrome, which commonly leads to the choice to abort the fetuses with those conditions. However, according to a recent article in The Conversation by Jeremy Williams one of the major concerns is the use of this technique to facilitate sex-selection abortion. Williams states that one of the major political parties has proposed a policy of banning the use of NIPT for sex determination and has described sex-selective abortion as “incredibly unethical”.

Williams concedes that the idea that sex-selection abortion is morally wrong and ought to be prevented is widely held even by those who otherwise have no moral objection to abortion but suggests that taking that position is problematic for those who believe that a woman has a right to choose to have an abortion. Williams lists several reason that people give for why the sex-selection abortion is wrong. These include idea that sex selection abortions are done due to a trivial preference, concern that sex selection abortion constitutes unjust discrimination against female fetuses, concern about women being coerced into this type of abortion, and that it teaches that the lives of girls are not as important as boys. He is concerned that if these reasons are accepted they would apply more broadly than to just this one type of abortion, and he is right. Many abortions are done for reasons that seem trivial compared to the value of the life of the fetus. Any abortion that is done because of the characteristics of the fetus, including having a genetic disorder such as Down syndrome, are both unjust discrimination against those who have such a disorder and express a message that people who have such a disorder do not have the same value as those who do not. Many women are pressured into having abortions, and do not actually freely choose them.

The problem with what Williams has written is that sex-selection abortion is just clearly wrong. It is wrong to kill a fetus because that fetus is female and end the life of the girl and woman who that fetus would have become just because she is female. That is a clear violation of women’s rights. The fact that this helps us see that abortions in other situations are also clear violations of more universal human rights should make people question whether those abortions are also wrong. It does not mean that sex selection abortion is permissible.

Choosing to die

When people present an argument for the moral permissibility of euthanasia they commonly start with a case in which a person is suffering from a terminal illness and has uncontrolled pain. They say that we should have no moral reason to say that it is wrong to assist those in such a condition who choose to end their life as a means of ending their suffering. This is a combination of two arguments. One is the argument from compassion that says that we have a moral obligation to minimize suffering and that euthanasia should be used if it is the most effective way to eliminate a person’s suffering. The other is the argument from respect for autonomy that says that people should be able to make decisions about their own lives, which should include the decision to end their lives, and that their physicians should respect those decisions. It has been pointed out by many who take the position that euthanasia is wrong that if these are good arguments for the permissibility of euthanasia they should be able to stand on their own. If we take these arguments individually, they lead places we should not want to go.

A couple of weeks ago I wrote about the concerns that many who live with disabilities have regarding the argument from compassion. It says that it can be the right thing to do to end a person’s life when that life is no longer worth living. They are concerned that if they become unable to make their own decisions someone will decide their lives are not worth living and they will be euthanized nonvoluntarily.

A recent case of joint euthanasia by a married couple in their mid-nineties in Canada reported in the Globe and Mail shows what can happen when the argument from respect for autonomy is taken by itself. George and Shirley Brickenden, who had been married for nearly 73 years, choose to die together. They died by lethal injection while lying on their bed holding hands in the presence of their children and clergyman. There was question about whether they both met the criteria of the Canadian law, which requires that the person receiving assisted death be suffering intolerably from a grievous and irremediable condition and that death is reasonably foreseeable. Even though Shirley suffered from long-standing rheumatoid arthritis and heart problems and George had recently begun having fainting spells from a heart rhythm problem, the primary reason for choosing euthanasia was that they did not want one of them to die and leave the other behind.

If the argument from compassion is a reason to accept euthanasia then we must accept nonvoluntary euthanasia in spite of the concerns of those with disabilities. If the argument from respect for autonomy is a reason to accept euthanasia then we must accept euthanasia for any reason given by a rational person including the desire of a married couple not to have one spouse survive longer than the other.

Rather than going to these extremes it seems reasonable to accept that there are limits to the things we ought to do to diminish suffering and there are limits to how far we should go in respecting a person’s autonomy. The intentional killing of an innocent person lies outside those limits.

Euthanasia and those who live with disabilities

This week the students in the medical ethics class that I teach are looking at the issue of euthanasia and physician assisted suicide. An article in The Catholic Register reminded me of the important role that people with disabilities have played in the public discussion of euthanasia. The article discusses the concerns that Taylor Hyatt, policy analyst and outreach coordinator for the disability rights group Not Dead Yet, has expressed about assisted suicide in Canada. She is concerned about proposals being considered to expand the Canadian Medical Aid in Dying (MAiD) law “to include mature minors, allow advanced directives for those with a dementia diagnosis, and allow MAiD for those with psychological suffering without the necessity of death being reasonably foreseeable.” She also expressed concern that under the present law no one is looking to see if those seeking assisted death have unmet accessibility needs that are pressuring them to end their lives.

From the earliest discussions about legalizing physician assisted suicide in the US, disability rights groups have played a significant role. They recognize that with any form of euthanasia the physician who chooses to assist in causing another person’s death must agree that the person’s life is not worth living. If we say that it is ever permissible for one person to say that another person’s life is not worth living, then it opens the door to people thinking that a the life of a person with disability is not worth living and that it would be best if that person’s life would be ended. Thus, even fully voluntary euthanasia puts those who are disabled at risk for nonvoluntary euthanasia. Actually many more than those with disabilities are at risk, but the marginalization that they experience makes them more sensitive to the risk.

We should listen to them.

Citizenship, Surrogacy and the Power of ART

A recent LA Times article by Alene Tchekmedyian explores a complicated case involving birthright citizenship, surrogacy and same-sex marriage. Briefly, a California man, Andrew Banks, married an Israeli man, Elad Dvash, in 2010. At the time, same-sex marriage was not legal in the US leaving Elad unable to acquire a green card for residency (via the marriage) so the couple moved to Canada where Andrew has dual citizenship. While in Canada, the couple conceived twin boys, Aiden and Ethan, using assisted reproduction technology (ART) whereby eggs from an anonymous donor were fertilized by sperm from Elad and Andrew and then implanted within the womb of a female surrogate and carried to term. When the US Supreme Court struck down the federal law that denied benefits to legally married gay couples in 2013, Elad applied for and was granted his greed card. The present controversy occurred when Andrew and Elad applied for US passports for the twins. US State Department officials required detailed explanation of the boys’ conception, eventually requiring DNA tests which confirmed Aiden to be the biological son of Andrew and Ethan to be the biological son of Elad. Aiden was granted a US passport while Ethan was denied. The family has since traveled to the US (Elad with his green card and Ethan with his Canadian passport and temporary 6 month visa) where they are now suing the State Department for Ethan’s US birthright citizenship. They are arguing that the current applicable statute places them wrongly in the category of children born out of wedlock rather than recognizing their marriage, thus discriminating against them as a binational LGBTQ couple.

Birthright citizenship is a complicated legal arena and I am no lawyer. The US is even more complicated because we allow birthright citizenship to be conferred jus soli (right of the soil) in addition to jus sanguinis (right of blood). The twins were not born in the US so establishing “bloodline” is needed. The law specifies conditions where one parent is a US citizen and one is not a US citizen, and there is further differentiation depending on whether the children of the US citizen were born in or out of wedlock. They also vary depending on whether the US citizen is male or female, with the law more lenient (easier to acquire citizenship) for the child of a woman than of a man.

While the legal challenge here will almost certainly involve potential issues of discrimination of LGBTQ binational couples, the problem is really with the current legal definitions of parent as it relates to surrogacy in general. The State Department actually has a website dedicated answering questions related to foreign surrogacy and citizenship. The real issue is that the State Department relies upon genetic proof of parentage for foreign surrogacy births. In the present case, the surrogacy occurred outside the US, Elad is the genetic father of Ethan and Elad is not a US citizen; therefore Ethan is not a US citizen. While I’m deep in the weeds here, technically, Aiden and Ethan are not fraternal twins in the usual sense but rather half siblings (and this assumes that the donor eggs are from the same woman; otherwise the boys would be unrelated despite sharing the same pregnant womb through the magic of ART). Had Ethan been physically born via surrogacy in the US, he would have acquired his citizenship via jus soli (see US map for surrogacy friendly states near you).

This problem is just as confounding for heterosexual couples using foreign surrogates, and the problem is global. A more detailed technical legal discussion may be found here. A heterosexual couple using donor eggs and donor sperm and using a foreign third party surrogate would have exactly the same problem establishing US citizenship for “their” child. A similar problem would exist for an adopted embryo gestated in a foreign country by a foreign surrogate. If either the egg or the sperm of the US citizen is used for the surrogate birth, the child would be granted birthright citizenship.

The main difference for homosexual couples is that only one spouse can presently be the biological parent. I say “presently” because with ART it is theoretically possible (and may become actually possible in the future) to convert a human somatic cell into either a male sperm or a female egg. At that point, both spouses within a same-sex marriage could be the biological parents of their child. The present legal issue is not the result of a cultural prejudice against anyone’s sexuality but with the biological prejudice of sex itself. ART has the potential ability to blur the categories of sex as culture is now blurring the categories of gender. Should we consider this a good thing?

Given the present technological limits of ART, the simple issue of US citizenship could be resolved in all these cases if the US citizen parent simply adopted the child. Elad correctly points out that while adoption of Ethan by Andrew would grant Ethan US citizenship, it would not grant Ethan birthright citizenship, a necessary requirement for Ethan to someday run for US president. ART may be forcing us to look at changing our definition of parent but should it change our definition of biology? Ethan is the biological son of Elad. He is able to be the legally adopted son of Andrew and enjoy the benefits of US citizenship as currently does his half brother Aiden. He is not able to become the biological son of Andrew and enjoy the additional benefit of birthright citizenship via jus sanguinis.

Should we change the definition of birthright citizenship because ART is changing our definition of parent?

Distorted views of the human person

After writing about how the events of the first Christmas influence how we think about personhood I read something that made me realize how distorted some of the views of personhood are in our society. I was reading an essay by James Toomey in the Hastings Center Bioethics Forum titled “Is Noninvasive Prenatal Genetic Testing Eugenic?” Toomey was responding to an earlier article by Vardit Ravitsky in which Ravitsky draws on a disability rights argument to say that the promotion of widespread prenatal testing and abortion as a means of reducing the societal burden of genetic disease is morally problematic and a form of eugenics in its negative sense. Toomey says that Ravitsky’s concern is not valid.

Setting aside the moral concerns about abortion done for any reason, the thing that struck me was one of Toomey’s arguments. He says that reducing the number of people with genetic disorders by prenatal testing and abortion “is closer to a cure than an assault on personhood.” He says that “narrative or social identity is what we care about when we think about personhood.” Therefore, if a couple plans to have a child, conceives, discovers the child will have Down syndrome, aborts the child, and then conceives again and gives birth to a child without Down syndrome, he says this can be seen as involving a single person who has been cured of Down syndrome. He claims this removes the eugenic associations from prenatal testing to reduce the number of people in society with a disorder such as Down syndrome.

Saying that the two children in this scenario, one aborted and one brought to birth, can be considered one child even though they are genetically distinct and conceived at different times is a serious problem with this view of personhood. We live in a time in which people believe at once the contradictory ideas that the only things that are real and knowable are those things that are material and empirically verifiable and that human persons are completely nonmaterial entities defined by narrative and social identity. The latter leads to this bizarre idea that these two distinct children, one dead and one living, are one person. The first leads to other problems.

It turns out that this is another place in which our understanding of Jesus can help us understand who we are as human beings. The early church had to deal with heresies that said that Jesus was either physically real but not divine or divine but not a physical being. The early creeds addressed these ideas by asserting the biblical truth that Jesus was both a physical and spiritual being who was at the same time fully human and fully divine. In a similar way human beings are composed of intimately connected material and immaterial aspects of who we are. Denying either of those aspects of our being leads to great misunderstanding of who we are. Not understanding who we are leads to poor ethical judgments.

Racial inequalities in cancer survival

Three studies published in a supplemental issue of the journal Cancer this month come to disturbing conclusions: in the United States, the survival rates for colon, breast, and ovarian cancer are lower for black people than for white people.

The news isn’t all bad: overall cancer survival rates are going up. The three studies mentioned here draw from two larger studies of worldwide cancer survival, the CONCORD study, published in 2008, and the CONCORD-2 study, published in 2015. Between CONCORD and CONCORD-2, cancer survival increased across all groups. But in both studies, the survival of black people in the United States lagged behind that for white people by about 10%.

Now there are certainly many reasons for the difference. Black people may be getting diagnosed with cancer at later stages, when survival is lower. There may be differences between the two groups, like genetic factors or the presence of other illnesses, that cause the cancers to be more aggressive in blacks. Mistrust of the health care system is more common among black patients, so they may be less likely to access care or access it early enough.

But other reasons include socio-economic status and access to health care; those who can’t access medical care because they can’t afford it or because it is not available nearby are less likely to receive necessary screening and treatment. And most troubling is the “consistent finding that black women do not receive guidelines-based treatment compared with white women, even when treated within the same hospital.”

The situation is too complex for simplistic answers; one can’t say from these studies that doctors are individually practicing blatant racism, and there is after all such a thing as systemic racism. But the medical profession should take such findings seriously, and seek every available avenue of education and self-monitoring to ensure that of all the places people encounter racism, the health care system is not one of them. And Christians especially, who believe that God created all people with equal dignity because all of us are created in His image, should work towards a health care system where the value — or length — of one’s life does not vary based solely on the color of one’s skin.

Gender-Optional Birth Certifcates: A Parental Lesson

I’ve been parenting for over fourteen years now, and I’d think it should offer some seasoning and an accumulation of wisdom. Yet the parental “goalposts” are continually being moved as my own children grow into young adults, and (to throw in another metaphor) I enter uncharted waters every day. Current parenting choices are often met with rejoinders by myself and others, and regrets mount over past choices. Cheerfully, based on reports from those who preceded me, I find that it’s entirely expected. Parenting means making mistakes. And as my older children enter high school, I catch myself living vicariously through their triumphs, joys, and agonies. The tension is great to give them space to be their own people, not enlightened versions of me that will triumph over that which I never could. But it’s a struggle.

At the same time, and I don’t know if it’s advancing age or a sign of our times, I think I appreciate the satirical more now than ever. It seems that, if we can laugh about ourselves, we may be able to put our differences in perspective and not take ourselves quite so seriously. Sometimes “hard news” even reads like satire. It has been a few months now, but I thought that a friend who linked me to an article in the Canadian Broadcasting Company’s story was sharing a satirical piece. He was not.

My high school English teacher would read the pronouns and capitalization choices in that piece as an aneurism-inducing affront to all she held dear. I’m not sure I’ll be able to comment without upsetting her, me, and many others, in grammatical terms alone. In short, a transgender Canadian, Kori Doty, fought to keep the gender identification on their (grammatical groan) child, Searyl Atli, unspecified, stipulating that the child would not…and should not be expected to…have fully formed a gender identity until later in life. Gender identity is fluid, and a birth certificate should recognize that. According to Kori’s attorney, “assigning gender at birth is a violation of a child’s human rights to freely express their gender identity.” Cis-entitlement is not a satirical construct, but a point of great contention and injustice, and the violation of a basic human right, to those included in this piece.

A few months of pondering later, as a parent I can, in some ways, relate to Kori, who is making a choice with which I disagree, with some sympathy. Kori wants baby Searyl to be empowered to overcome the pain that gender identity struggles have already been lived in their life. Yes, there is also a clear political agenda, in the creation of a human right that society has never recognized, and I have far less respect for that. But I know the evangelical church has a history of poor responses to issues of sexual identity, on a political and relational level. I have limited personal experience with transgender individuals, and recognize that ethical decisions are not best made anecdotally, but even that limited experience has revealed that they have complex and challenging, and often extraordinarily painful, life stories. None have seemed capricious in their decisions. Some have been born with undetermined genitalia that truly weren’t clearly determinative of their gender. Others struggled with the very essence of who they were, even as anatomy would have seemed determinative.

The complexity of this issue should be sobering to us all, and particularly to those who embrace the Christian message that fully recognizes the devastation of a fallen world and the remarkable promise of grace that is not yet fully realized. I encourage the church to look at a complex issue with cautious, winsome eyes. The evangelical church lost its place at the table on the discussions of homosexuality (one where its voice could and should have been compelling) because too many showed graceless insensitivity. The high suicide rate of those who identify as transgender should be heartbreaking to the church. I am convicted as I initially read the article as unintentional satire.

Yet this is another issue where the complexity of medicine and social science is subordinated to a cultural agenda. There is, frankly, nothing wrong with asking for time and space to better study and understand the many pieces of the puzzle that transgenderism includes. The cry to “affirm” that which I can’t yet understand is unreasonable, even in the name of compassion. The appeal of bioethics is the way it synthesizes the disciplines of medicine, social science, theology, philosophy, and public policy, and recognizes the importance of each. I would like to think parents are the best arbiters of their children’s interests. Sadly, this story, and my own vicarious desires for my children, remind me otherwise. This parent has instrumentalized a child. The choice, if repeated on a mass scale, leads to social chaos and places a staggering stress on children whose developmental biology already faces challenges in our culture. Even now, we see gender reassignment surgery performed on young people. A sobering piece from a bit ago in The Federalist likens these surgeries with the frontal lobotomies of the 1930’s. Medicine needs to be exceedingly cautious as it encounters the “human right” that is gender identity. May bioethicists recognize the great complexity of transgenderism through eyes of compassion and grace, yet not submit medical and ethical wisdom to a cultural agenda. And may parents be wise enough to realize when we place the burdens of our agendas upon our children, whatever those agendas may be.

Hugh Heffner’s Legacy

Hugh Heffner died on Wednesday, September 27 in his Playboy mansion at the age of 91.  He was buried next to Marilyn Monroe, Playboy’s inaugural centerfold.

From the moment I heard that Heffner had died, I tried to process the significance of his life and death.  Part of me feels sadness and pity.  As a Christian, I can’t get one thought out of my mind.  What would it be like to stand before the Holy God and give an account of your life, when your claim of fame was bringing pornography into the mainstream?  Frankly, I’ve had to fight being too judgmental and too self-righteous.  After all, despite all my weaknesses, failures, and sins, Hugh Heffner makes me look good.  Yet, I too will one day give an account of my life before God.  Only by the grace of God, the blood of Jesus, and the cleansing of the Holy Spirit have my own filthy rags of unrighteousness been removed and replaced with the righteousness of Jesus.  Oddly, Heffner’s death has caused me to be more self-reflective and more determined to live righteously and to uphold high ethical standards.

Another part of me, however, is angry.  I’m angry because Heffner launched a magazine and an empire that pedals to our base, fallen, lustful desires and, in doing so, he bears the guilt of bringing thousands—even millions—of people into moral ruin.  For many men of my generation, Playboy was the introduction to pornography, a fascination that turned into a habit that turned into an addiction that resulted in personal ruin.  That fascination turned habit turned addiction is fueled even more powerfully today by easy access to internet porn that makes the original Playboy magazine look tame.  Indirectly at least, Heffner is responsible for aiding the destruction of the marriages, moral lives, and Christian walk of many friends and relatives of mine. Yes, I’m angry.  I pray my anger is “righteous anger.”  My heart breaks over the devastation that has been wrought by the sexual revolution of which Heffner’s legacy is a part.

Many authors of various news reports, articles, and blogs about Heffner’s life and death are not quite sure how to view his legacy.  For the most part, television news reports have been bland and blindly uncritical.  The obituaries for Hefner, even if they acknowledge the coarseness and unseemliness of his empire, have been full of praise for his great deeds as the conqueror of puritanism, as the advocate of progressive political issues, and as the successful businessman.

Feminists writers especially are at a wit’s end.  Take, for example, an article by feminist writer, Jill Filipovic (“No, Hugh Hefner Did Not Love Women”).  On the one hand, she commends Hefner for being “on the right side of many of the biggest issues of the modern era: free speech, reproductive choice, gay rights.” Personally, I don’t agree that Heffner and progressives are on the “right side” of these issues, but I concur that they are on the same side, as Filipovic notes.  While she upholds abortion rights as strongly as Heffner did, she does part company with him in one regard: “Hefner advocated for contraception and abortion rights, sure, but because those things benefited men’s sex lives, not because they were necessary components of female freedom.”

On the other hand, Filipovic condemns Hefner for reducing women to mere playmates, objects of men’s fantasies and unbridled desires.  I could not agree with her more on this point.  She observes, rightly in my opinion: “Hefner claimed to ‘love women.’ He certainly loved to look at women, or at least the type of women who fit a very particular model. He loved to make money by selling images of women to other men who ‘love women.’ He certainly met a lot of women, had sex with a lot of women, talked to a lot of women. But I’m not sure Hefner ever really knew any of us. And he certainly did not love us.”

Especially insightful is this point: “What Hefner and Playboy never did was present women as human, or consider us anything like men. Hefner made female sex objects more relatable and accessible — the Playboy centerfold was the girl next door, not the famous movie actress —but this wasn’t so much an elevation as a downward shift: social permission for men to look at all women through the zipper in their jeans, and not even bother to pretend it was otherwise.”

On this point, Filipovic is in agreement with conservative, Christian blogger Jon Bloom (“One Man’s Dream Destroyed Millions: The Pitiful Legacy of Hugh Hefner”): “Hefner and many others have become very rich by objectifying women and turning them into virtual prostitutes—mere bodily images to be used by millions of men who care nothing about them, who ravage them in their imaginations for selfish pleasure and then toss them in the trash. Hefner gave these women the fun name of “playmates,” a wicked mockery of both a person and play, adding a terrible insult to horrible injury.”

On at least this point, a progressive and a conservative writer can agree.  The objectification of women—the reduction of women to “mere body,” as if they were devoid of mind, emotion, and soul—is pornography’s ultimate evil.  I also agree.

 

Most pressing bioethics issue

In yesterday’s post Mark McQuain asked the readers of this blog what they consider to be the most pressing bioethics issue in the context of a call for our president to establish a bioethics council. He referred to my recent post on reproductive ethics and the manufacturing of children. I think that is important. I also think that abortion including the aborting of children with developmental abnormalities such as Down syndrome, euthanasia, and the treatment of children with gender dysphoria are very important. However, my most pressing concern related to bioethics in our society is freedom of conscience.

It is important that we express clearly the value of human life and how that impacts how we understand the ethics of things such as reproductive technology, abortion and euthanasia, but we are living in a time in which many do not listen to reasoned arguments about what is right. Much of our society believes that what is right is determined by how they feel and they desire to be free of any limits on what they can do. They also believe, somewhat contradictorily, that they should be affirmed in being able to do what they desire by having society help them do it; even if that means that others need to do things that they believe to be wrong. Our society is losing the concept of any objective moral values. Without objective moral values it does not make sense for someone to refuse another person’s request for help in fulfilling their desires based on conscience, particularly conscience informed by an objective understanding of right and wrong. If there is no objective standard on which to refuse such a request the refusal must involve some sort of personal rejection of the one making the request.

Thus we have ACOG saying their members must affirm patients who desire an abortion. Canadian physicians may soon be required to affirm their patients’ desire for euthanasia. There is a push for physicians, psychologists and others to be required to affirm the desire for a confused child to be identified as having a gender that is in conflict with the child’s biological sex. As Cheyn Onarecker has discussed in his posts yesterday and last week, there are some prominent ethicists who give reasoned, although faulty, arguments against rights of consciences for physicians.

The elimination of rights of conscience threatens the ability of not only Christian physicians but all people of strong moral conviction in all professions to practice their professions without violating their consciences. If allowed to go unchecked the demand to affirm every request by every person in the name of pluralism and personal liberty will leave every profession in our society without those who are most conscientious. It will also lead to the demise of ethics as a disciple. If our society really believes that there are no objective moral truths and everyone should be free to pursue his or her desires and enlist others in that pursuit, then any statement that an action is wrong will not be seen as a particular understanding of what is right and wrong which can be civilly discussed, but as an unfounded personal attack on someone who desires to do that action. Thus there will be reason to shut down all ethical discussion and the discipline of ethics will be forbidden.

Inner Sense and Gender Dysphoria

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.