Gender dysphoria and transition, part 3: Medical intervention?

In my last post, a couple of days ago, I argued that gender dysphoria is a real phenomenon, in the sense that there are people who are unhappy to have been assigned to a particular sex at birth and wish they were the other sex. To be completely clear, I am not speaking here only — or even primarily — of those who were born intersex, or whose sexual morphology is somehow ambiguous at a biological level. While those who are biologically intersex are naturally involved in this discussion, my focus is on those whose biological sex is unambiguous but who are made unhappy or miserable by it.

The second thing I argued in the earlier post is that gender (including how one presents oneself to others) is a social and cultural category; and is therefore different from sex, which is a biological category. And I added furthermore that while there are mostly two sexes in a biological sense (always excepting the intersex), there could in principle be almost any number of genders in a social or cultural sense. Therefore, if you were raised to present yourself one way, but you now feel profoundly called to present yourself in a different way, I see no logical reason to dissuade you. Regardless which sex you belong to biologically, you might belong to a hitherto-unknown gender culturally; and therefore you should be free to express yourself as such.

The next step, naturally, is that the sufferer says, "Look, I identify only with that sex. Of course it's great that I can dress like them and act like them, but I want my body to correspond with them as well. I want to belong to that sex when I take my clothes off. And modern medicine can do amazing things. So I want medical intervention to change me into a member of that sex."

How should we think about this request? What is the best way to respond to this desire?

I think the only reasonable place to start is with the very same premise on which I built my previous argument, namely, a general confession of human ignorance. There is a lot that we don't know. But in this case it is important to recognize that this ignorance applies even in areas we are proud of. In particular, yes, modern medical techniques represent a huge advance over the techniques common even one or two centuries ago. But for exactly that reason, I am convinced that by the standards of one or two centuries in the future, today's medicine will be seen as all-too-primitive. Doubtless the people then will give us credit for doing the best we could with such limited knowledge as we have today; but I expect us still to learn so much about the body — things that we don't know yet — that it will beggar description.

The medical techniques used to enable gender transition typically involve a combination of surgery and hormone therapy. Each of these is a significant intervention in the body system as a whole. And I think we do not understand all the side-effects of these interventions. Sex reassignment surgery is vastly more complex than, say, appendectomy. It affects systems that interact with every other part of the body. And it is therefore not credible that anyone can have calculated what the all consequences will be.

Therefore, I think it is only prudent to avoid any such surgery or treatment — at least until our knowledge is a lot fuller and our skill is a lot greater than it is today. I assume that in two hundred years, people will look back on our age and say in wonderment, "Can you believe the kind of surgeries they did back in the early twenty-first century? By comparison with what we know today, they might as well have been witch-doctors working with kitchen knives! It's a miracle any of their patients survived."

Less fancifully, every year patients die in surgery. Every year, doctors make mistakes that ruin the lives of their patients — that's why doctors all have to carry malpractice insurance. In the face of these indisputable facts, honestly, it is prudent to avoid any surgery unless there is no alternative. 

As I write this, I am aware that there are some people for whom such a transition brings about a significant improvement in their lives. I have written about one such story (one I heard second-hand) in another venue, describing the patient as "A young man very angry with the world." According to the story as I heard it, he was a lot less angry with the world after becoming a woman. So yes, for some people their lives afterwards are better.

But there is no way to know in advance whether this person in particular will be one of the ones whose lives get better, and there is no way to know in advance what other subsystems of the body might be disrupted by the treatment. Moreover, it's not a two-way street: if the surgery doesn't bring the desired results, one can't go back. This is the line between science fiction and medical reality. We do not live in Beta Colony, and we should not expect to benefit from the miraculous technology that the Betans take for granted.

I said in the beginning of this essay that I would not primarily discuss the intersex, but if I say nothing whatever about them I will be called to account for the omission. But here I would avoid making any general rule, suggesting instead that each case be addressed individually through deep consultation between doctor and patient. If there is no need for serious intervention, I think (as suggested above) that prudence cautions us not to intervene seriously. Naturally if there is a situation that has to be addressed — because the patient simply cannot live with the status quo, for whatever reason — then address it.

Update added May 10, 2022: Just this morning I ran across a blog post from four years ago by a trans woman who discusses her experience with some precision. You can find it here. Her description does not make me change my mind about any of what I wrote here.