Can a boy truly be “trapped” in a girl’s body? Can modern medicine really “reassign” sex? Is sex something “assigned” in the first place? What’s the loving response to a friend or child experiencing a gender identity conflict? What should our law say on these issues?
These shouldn’t be difficult questions.
Thirty years ago, Dr. Paul McHugh thought he had convinced the vast majority of medical professionals not to go along with bold claims about sex and gender being proffered by some of his colleagues. And as chair of psychiatry at Johns Hopkins Medical School and psychiatrist-in-chief at Johns Hopkins Hospital, McHugh put a stop to sex-reassignment surgery at Hopkins.
Once the elite Johns Hopkins did this, many medical centers across the nation followed suit. But in recent years we have seen a resurgence of these drastic procedures—not in light of new scientific evidence, mind you, but as a result of a growing ideological movement. Such is our transgender moment.
The people increasingly in the spotlight of this moment are children.
In the past 10 years, dozens of pediatric gender clinics have sprung up throughout the United States. In 2007, Boston Children’s Hospital “became the first major program in the United States to focus on transgender children and adolescents,” as its own website brags. A decade later, over 45 gender clinics opened their doors to our nation’s children—telling parents that puberty blockers and cross-sex hormones may be the only way to prevent teen suicides.
Never mind that according to the best studies—the ones that even transgender activists themselves cite—80 to 95 percent of children with gender dysphoria will come to identify with and embrace their bodily sex.2 Never mind that 41 percent of people who identify as transgender will attempt suicide at some point in their lives, compared to 4.6 percent of the general population.3 Never mind that people who have had transition surgery are 19 times more likely than average to die by suicide.4 These statistics should stop us in our tracks. Clearly, we must work to find ways to effectively prevent these suicides and address the underlying causes.
Many psychologists and psychiatrists think of gender dysphoria as similar to other dysphorias, or forms of discomfort with one’s body, such as anorexia. The feelings of discomfort can lead to mistaken beliefs about oneself or about reality, and then to actions in accordance with those false beliefs. The most helpful therapies focus not on achieving the impossible—changing bodies to conform to thoughts and feelings—but on helping people accept and even embrace the truth about their bodies and reality.
Operating in the background is a sound understanding of physical and mental health—proper function of one’s body and mind—and a sound understanding of medicine as a practice aimed at restoring health, not simply satisfying the desires of patients. For human beings to flourish, they need to feel comfortable in their own bodies, readily identify with their sex, and believe that they are who they actually are.
In my new book, When Harry Became Sally: Responding to the Transgender Moment, I argue that McHugh got it right. The best biology, psychology, and philosophy all support an understanding of sex as a bodily reality, and of gender as a social manifestation of bodily sex. Biology isn’t bigotry.
Transgender activists reject much of this. But before proceeding I want to draw a distinction between people who are experiencing gender dysphoria and ideologues who embrace and promote transgender ideology. Many people who suffer from gender dysphoria reject the activists’ claims and should themselves be regarded as victims of the activists. Many of those who feel distress over their bodily sex know that they aren’t really the opposite sex, and do not wish to “transition.” They wish to receive help in coming to identify with and accept their bodily self.
Imagine feeling so alienated from your own body that you would contemplate removing some of your own body parts. These people are suffering, and they are being fed bad advice from the professionals in their lives. The critique of this essay is at those ideologues, not at the individuals experiencing gender dysphoria. If anything, we should have abundant charity for people who feel alienation from their own bodies. But we should insist on telling the truth about those who are promoting a faulty anthropology.
People say that we live in a postmodern age that has rejected metaphysics. That’s not quite true. We live in a postmodern age that promotes an alternative metaphysics. As I explain in When Harry Became Sally, at the heart of the transgender moment are radical ideas about the human person—in particular, that people are what they claim to be, regardless of contrary evidence. The rhetoric of the transgender moment drips with ontological assertions: people are the gender they prefer to be.
Transgender activists don’t want to have the debate on the level of philosophy, so they dress it up as a scientific and medical claim. And they’ve co-opted many professional associations for their cause. Thus the American Psychological Association tells us, “Transgender is an umbrella term for persons whose gender identity, gender expression, or behavior does not conform to that typically associated with the sex to which they were assigned at birth.”5 Notice the politicized language: a person’s sex is “assigned at birth.”
This phrase is now favored because it makes room for “gender identity” as the real basis of a person’s sex. In an expert declaration to a federal district court in North Carolina concerning H.B. 2 (a state law governing access to sex-specific restrooms), Dr. Deanna Adkins stated, “From a medical perspective, the appropriate determinant of sex is gender identity.”6 Adkins, director of the Duke Center for Child and Adolescent Gender Care, argues that gender identity is not only the preferred basis for determining sex, but “the only medically supported determinant of sex.”7 Every other method is bad science, she claims.8
But what exactly is this “gender identity”? Adkins defines it as “a person’s inner sense of belonging to a particular gender, such as male or female.”9 Note that little phrase “such as,” implying that the options are not necessarily limited to male or female. Other activists are more forthcoming in admitting that gender identity need not be restricted to the binary choice of male or female, but can include both or neither.
These notions about sex and gender are now being taught to young children. Activists have created child-friendly graphics for this purpose, such as a “Gender Unicorn.”10 It has a body shape that doesn’t appear either male or female, and instead of a “biological sex” it has a “sex assigned at birth.” According to its creators, “Biological sex is an ambiguous word that has no scale and no meaning besides that it is related to some sex characteristics. It is also harmful to trans people. Instead, we prefer ‘sex assigned at birth’ which provides a more accurate description of what biological sex may be trying to communicate.”11 The Gender Unicorn is the graphic that children are likely to encounter in school. These are the dogmas they are likely to be catechized to profess.
If the claims presented in this essay strike you as confusing, you’re not alone. The thinking of transgender activists is inherently confused and filled with internal contradictions. Activists never acknowledge those contradictions. Instead, they opportunistically rely on whichever claim is useful at any given moment.
On the one hand, they claim that the real self is something other than the physical body, in a new form of Gnostic dualism, yet at the same time they embrace a materialist philosophy in which only the material world exists. They say that gender is purely a social construct, while asserting that a person can be “trapped” in the wrong gender. They say that there are no meaningful differences between man and woman, yet they rely on rigid sex stereotypes to argue that “gender identity” is real, while human embodiment is not. They claim that truth is whatever a person says it is, yet they believe there’s a real self to be discovered inside that person. They promote a radical expressive individualism in which people are free to do whatever they want and define the truth however they wish, yet they try ruthlessly to enforce acceptance of transgender ideology.
It’s hard to see how these contradictory positions can be combined. If you pull too hard on any one thread of transgender ideology, the whole tapestry comes unraveled. But here are some questions we can pose: If gender is a social construct, how can gender identity be innate and immutable? How can one’s identity be unchangeable with respect to an ever-changing social construct? And if gender identity is innate, how can it be “fluid”? The challenge for activists is to offer a plausible definition of gender and gender identity that is independent of bodily sex.
Is there a gender binary or not? Somehow, it both does and does not exist, according to transgender activists. If the categories of “man” and “woman” are objective enough that people can identify as, and be, men and women, how can gender also be a spectrum, where people can identify as, and be, both, or neither, or somewhere in between? What does it even mean to have an internal sense of gender?
What does gender feel like? What meaning can we give to the concept of sex or gender—and thus what internal “sense” can we have of gender—apart from having a body of a particular sex? Apart from having a male body, what does it “feel like” to be a man? What does it feel like to be both a man and a woman, or to be neither? The challenge for the transgender activist is to explain what these feelings are like, and how someone could know if he or she “feels like” the opposite sex, or neither, or both.
Even if trans activists could answer these questions about feelings, that still wouldn’t address the matter of reality.
Why should feeling like a man—whatever that means—make someone a man? Why do our feelings determine reality on the question of sex, but on little else? Why should a person’s “real” sex be determined by an inner sense of identity, but not a person’s age, height, race or species?
Of course, a transgender activist could reply that an “identity” is, by definition, just an inner sense of self. But if that’s the case, gender identity is merely a disclosure of how one feels. Saying that someone is transgender, then, says only that the person has feelings that he or she is the opposite sex.
Gender identity, so understood, has no bearing at all on the meaning of “sex” or anything else. But transgender activists claim that a person’s self-professed “gender identity” is that person’s “sex.” Activists must explain why the mere feeling of being male or female (or both or neither) makes someone male or female (or both or neither).
Gender identity can sound a lot like religious identity, which is determined by beliefs. But those beliefs don’t determine reality. Someone who identifies as a Christian believes that Jesus is the Christ. Someone who identifies as a Muslim believes that Muhammad is the Final Prophet. But Jesus either is or is not the Christ, and Muhammad either is or is not the Final Prophet, regardless of what anyone happens to believe. So, too, a person either is or is not a man, regardless of what anyone—including that person—happens to believe.
The challenge for transgender activists is to present an argument for why transgender beliefs determine reality. If gender identity is self-created, why must other people accept it as reality? If we should be free to choose our own gender reality, why can some people impose their idea of reality on others just because they identify as transgender? Another challenge for the transgender activist is to articulate some conception of truth as the basis for how we understand the common good and how society should be ordered.
There are human costs to getting human nature wrong. Contrary to the claims of activists, sex isn’t “assigned” at birth—and that’s why it can’t be “reassigned.” Sex is a bodily reality that can be recognized well before birth with ultrasound imaging. The sex of an organism is defined and identified by the way in which it (he or she) is organized for sexual reproduction. And that organization can’t be “reassigned.”
Modern science shows that our sexual organization begins with our DNA and development in the womb, and that sex differences manifest themselves in many bodily systems and organs, all the way down to the molecular level. In other words, our physical organization for one of two functions in reproduction shapes us organically, from the beginning of life, at every level of our being.
Cosmetic surgery and cross-sex hormones can’t change us into the opposite sex. They can affect appearances. They can stunt or damage some outward expressions of our reproductive organization. But they can’t transform it. They can’t turn us from one sex into the other.
“Scientifically speaking, transgender men are not biological men and transgender women are not biological women. The claims to the contrary are not supported by a scintilla of scientific evidence,” explains Dr. Mayer.12 Or, as Princeton philosopher Robert P. George put it, “Changing sexes is a metaphysical impossibility because it is a biological impossibility.”13
Sadly, just as “sex reassignment” fails to reassign sex biologically, it also fails to bring wholeness socially and psychologically. As I demonstrate in When Harry Became Sally, the medical evidence suggests that it does not adequately address the psychosocial difficulties faced by people who identify as transgender. Even when the procedures are successful technically and cosmetically, and even in cultures that are relatively “trans-friendly,” transitioners still face poor outcomes.
Dr. Paul McHugh explains:
Transgendered men do not become women, nor do transgendered women become men. All (including Bruce Jenner) become feminized men or masculinized women, counterfeits or impersonators of the sex with which they ‘identify.’ In that lies their problematic future.
When ‘the tumult and shouting dies,’ it proves not easy nor wise to live in a counterfeit sexual garb. The most thorough follow-up of sex-reassigned people—extending over thirty years and conducted in Sweden, where the culture is strongly supportive of the transgendered—documents their lifelong mental unrest. Ten to fifteen years after surgical reassignment, the suicide rate of those who had undergone sex-reassignment surgery rose to twenty times that of comparable peers.14
In 2014, a review of the scientific literature was done by Hayes, Inc., a research and consulting firm that evaluates the safety and health outcomes of medical technologies. Hayes found that the evidence on long-term results of sex reassignment was too sparse to support meaningful conclusions and gave these studies its lowest rating for quality:
Statistically significant improvements have not been consistently demonstrated by multiple studies for most outcomes…Evidence regarding quality of life and function in male-to-female (MtF) adults was very sparse. Evidence for less comprehensive measures of well-being in adult recipients of cross-sex hormone therapy was directly applicable to GD patients but was sparse and/or conflicting. The study designs do not permit conclusions of causality and studies generally had weaknesses associated with study execution as well. There are potentially long-term safety risks associated with hormone therapy but none have been proven or conclusively ruled out.15
The Obama administration came to similar conclusions. In 2016, the Centers for Medicare and Medicaid revisited the question whether sex reassignment surgery would have to be covered by Medicare plans. Despite receiving a request that its coverage be mandated, they refused, on the ground that we lack evidence that it benefits patients.16 And when it comes to the best studies, there is no evidence of “clinically significant changes” after sex reassignment:
After careful assessment, we identified six studies that could provide useful information. Of these, the four best designed and conducted studies that assessed quality of life before and after surgery using validated (albeit non-specific) psychometric studies did not demonstrate clinically significant changes or differences in psychometric test results after GRS [gender reassignment surgery].17
In a discussion of the largest and most robust study—the study from Sweden that Dr. McHugh mentioned in the quote above—the Obama Centers for Medicare and Medicaid pointed out the nineteen-times-greater likelihood for death by suicide, and a host of other poor outcomes:
The study identified increased mortality and psychiatric hospitalization compared to the matched controls. The mortality was primarily due to completed suicides (19.1-fold greater than in control Swedes), but death due to neoplasm and cardiovascular disease was increased 2 to 2.5 times as well… The risk for psychiatric hospitalization was 2.8 times greater than in controls even after adjustment for prior psychiatric disease (18%).18
These results are tragic. And they directly contradict the most popular media narratives, as well as many of the snapshot studies that do not track people over time. The Obama Centers for Medicare and Medicaid pointed out that “mortality from this patient population did not become apparent until after 10 years.” So when the media tout studies that only track outcomes for a few years, and claim that reassignment is a stunning success, there are good grounds for skepticism.
As I explain in my book, these outcomes should be enough to stop the headlong rush into sex-reassignment procedures. They should prompt us to develop better therapies for helping people who struggle with their gender identity. And none of this even begins to address the radical, entirely experimental therapies that are being directed at the bodies of children to transition them.19
Transgender ideologues ignore contrary evidence and competing interests; they disparage alternative practices; and they aim to muffle skeptical voices and shut down any disagreement. The movement has to keep patching and shoring up its beliefs, policing the faithful, coercing the heretics, and punishing apostates, because as soon as its furious efforts flag for a moment or someone successfully stands up to it, the whole charade is exposed. A transgender future is not the “right side of history,” yet activists have convinced the most powerful sectors of our society to acquiesce to their demands. While the claims they make are manifestly false, it will take real work to prevent the spread of these harmful ideas.
- The term “transgender moment” has been used by people on the left and the right, in secular and religious media. See, for example, Brandon Griggs, “America’s transgender moment,” CNN, June 1, 2015; Sonali Kohli, “Pop Culture’s Transgender Moment: Why Online TV Is Leading the Way,” Atlantic, September 26, 2014; Deborah Sontag, “‘A Whole New Being’: How Kricket Nimmons Seized the Transgender Moment,” New York Times, December 12, 2015; Rebecca Juro, “Bruce Jenner and America’s transgender moment,” MSNBC, April 25, 2015; Justin Peligri, “After marriage, it’s a transgender moment,” Washington Blade, April 30, 2015; John W. Kennedy, “The Transgender Moment,” Christianity Today, February 12, 2008; Rand Richards Cooper, “The Transgender Moment,” Commonweal,December 16, 2015.
- For a discussion of the studies, see Paul R. McHugh, Paul Hruz, and Lawrence S. Mayer, Brief of Amici Curiae in Support of Petitioner, Gloucester County School Board v. G.G., Supreme Court of the United States, No. 16‑273 (January 10, 2017), 12.
- Anne P. Haas, Philip L. Rodgers, and Jody Herman, “Suicide Attempts Among Transgender and Gender Non-Conforming Adults: Findings of the National Transgender Discrimination Survey,” Williams Institute, UCLA School of Law (January 2014).
- Cecilia Dhejne et al., “Long-term follow-up of transsexual persons undergoing sex reassignment surgery: cohort study in Sweden,” PLOS ONE 6 (February 2011): e16885.
- American Psychological Association, “Answers to Your Questions About Transgender People, Gender Identity, and Gender Expression,” p. 1, http://www.apa.prg/topics/lgbt/transgender.pdf
- Declaration of Deanna Adkins, M.D., U.S. District Court, Middle District of North Carolina, Case 1:16-cv-oo236-TDS-JEP, p. 5.
- Ibid., 6.
- Ibid., 7.
- Ibid., 4.
- Trans Student Educational Resources, “The Gender Unicorn,” https://www.trans-student.org/gender.
- Declaration of Lawrence S. Mayer, M.D., M.S., Ph.D, U.S. District Court, Middle District of North Carolina, Case 1:16-cv-00425-TDS-JEP, Exhibit K.
- Robert P. George, “Gnostic Liberalism,” First Things, December 2016.
- Paul McHugh, “Transgenderism: A Pathogenic Meme,” Public Discourse, June 10, 2015 http://www.thepublicdiscourse.com/2015/06/15145/.
- Hayes, Inc., “Hormone therapy for the treatment of gender dysphoria,” Hayes Medical Technology Directory (Lansdale, Pa.: Winifred Hayes, May 2014), quoted in Cretella, “Gender Dysphoria in Children and Suppression of Debate,” 52. See also “Sex reassignment surgery or the treatment of gender dysphoria,” Hayes Medical Technology Directory(2014).
- Tamara Syrek Jensen et. al, “Proposed Decision Memo for Gender Dysphoria and Gender Reassignment Surgery,” U.S. Centers for Medicare and Medicaid Services, File No. CAG-00446N (June 2, 2016), https://www.cms.gov/medicare-coverage-database/details/nca-proposed-decision-memo.aspx?NCAId=282.
- Tamara Syrek Jensen et al., “Decision Memo for Gender Dysphoria and Gender Reassignment Surgery,” U.S. Centers for Medicare and Medicaid Services, File No. CAG-00446N (August 30, 2016), https://www.cms.gov/medicare-coverage-database/details/nca-decision-memo.aspx?NCAId=282&bc=ACAAAAAAQAAA&.
- Ibid., discussing Cecilia Dhejne et al., “Long-term follow-up of transsexual persons undergoing sex reassignment surgery: cohort study in Sweden,” PLOS ONE 6 (February 2011): e16885.
- See When Harry Became Sally, chapter 6 in particular.