Questioning the Gender-Affirming Paradigm

Recently, I came across a series of pictures from Our Landing Place, a mental health service, on Instagram. The pictures intend to debunk "myths" about gender-affirming care, which can be defined as "medical, social, and psychological approaches and therapies that aim to affirm a transgender patient's identity or align their physical characteristics more closely with their gender." In addition to insults like "extremist" and "anti-trans" being used to describe those with a different social philosophy than that of Our Landing Place, the post fails to direct the reader to any resources that would support its claims.

The certainty with which these claims are made, however, is not necessarily justified. I know this because I have come across information that does not cohere with the gender-affirming paradigm.

Here is the response to the first "myth," that gender-affirming care is too accessible: "Experts are reporting that gender affirming (sic) care is extremely hard for youths to access in Canada, which is putting trans and non-binary youth at risk of mental health challenges, including suicide."

This is an oft-repeated idea: either provide gender-affirming care, or the mental health of youth will be jeopardized, perhaps even to the point of suicide. However, Leor Sapir, a fellow at the Manhattan Institute, has written a thorough article where he argues to the contrary. Sapir claims, for instance, that teenagers who experience rapid-onset gender dysphoria (ROGD) "are known to have very high rates of anxiety, depression, history of sexual trauma, anorexia, and eating disorders, all of which typically precede their gender-related distress." It is possible (and even likely) that these factors would contribute to making someone suicidal, quite apart from them not receiving gender-affirming care.

Unfortunately, while Sapir includes many links to research in this article, the sentence that the above quotation is taken from does not include any. However, I was able to find this article (albeit retracted) by Suzanna Diaz and J. Michael Bailey that supports Sapir's claim. Parents of 1,655 adolescents and young adults experiencing gender dysphoria were surveyed. "On average, mental health problems . . .  preceded gender dysphoria by 3.8 years."

Now, to explain ROGD in more detail, it refers to a condition in which adolescents (especially females) "who showed no signs of gender dysphoria before puberty" experience an abrupt change in gender identity. As David Ludden notes in the article just linked to, however, it is a controversial concept in terms of causation. This is especially true of the social contagion hypothesis, which posits that ROGD is a misdiagnosis of gender dysphoria caused by social influence. While there is no shortage of activists who dismiss the concept entirely (see Wikipedia's article on it for an astounding example of ideological bias), I do not wish to take it off the table.

Returning to Sapir's article, this paragraph also caught my attention:

Many countries, including the United States, have media guidelines on how to report on suicide so as not to inadvertently encourage people to engage in the behavior. Among the things that the CDC has warned not to do is “[p]resenting simplistic explanations for suicide.” As the agency explains, “Suicide is never the result of a single factor or event, but rather results from a complex interaction of many factors and usually involves a history of psychosocial problems.” It's difficult to imagine a more “simplistic explanation” than “kids will kill themselves if their gender identity is not affirmed.”

Moving onto another "myth," concerning the likeliness of regret, Our Landing Place responds: "The regret rate of transitioning, scientifically, is below 1%. The regret rate of knee surgery is up to 30%."

However, a special report has been published by Reuters that renders this statement questionable. The authors—Robin Respaut, Chad Terhune, and Michelle Conlin—write: "Ever since the first clinic to offer gender care to minors in the United States opened in Boston 15 years ago, none of the leading providers have published any systematic, long-term studies tracking outcomes for all patients."

Not only is there a dearth of long-term studies on patient outcomes, which is surely important to consider if you are going to attach a definitive percentage to regret rates, but statistics on detransition rates are also ambivalent. According to Respaut, Terhune, and Conlin, the available (and limited) studies suggest that it ranges between less than 1% and up to 25%. It strikes me as intuitive that regret is a reason for detransitioning, even if it is not the only reason. So, it is not certain that "scientifically" the regret rate is below 1%, in which the use of the word "scientifically" appears to be motivated by a desire on the part of Our Landing Place to insulate their beliefs from any evidence to the contrary.

I will content myself with commenting on just one more picture, which is the last one in the series. The "myth" it rejects is that "[p]arents have rights." Our Landing Place responds by saying, "This is a campaign for power, not rights. Parents have responsibilities. Children have rights."

It is convenient that this Nietzschean sentiment omits any mention of activists in fields like mental health and education. For those who advocate for gender-affirming care—such as Our Landing Place—could also be accused of wanting power, namely, over policymakers and parents who do not agree with their ideology.

If parents do not have rights over their children, why should mental health professionals and educators who have no familial bond whatsoever?

Really, power is a marginal issue; at the heart of the matter is values. It is easy to resort to the emotionalism of using cliché words like "power" when different values eclipse one's own, but this misses the point. The reason people are motivated to exercise power over others in the first place is that they believe they know what is true and proper, while others do not. Questions of truth and ethics should be at the forefront of the discussion on gender-affirming care.

Meanwhile, basic questions like "Is it true that someone's gender can be separated from their body?" are completely overlooked, as the radical dualism of the sex-gender distinction has become taken for granted so as to hardly be questionable, despite the fact that in contemporary discussions on the philosophy of mind substance dualism is not particularly popular. 

It also seems to me that the ethics of gender-affirming care, at least in popular discourse, is reduced to consent and desire on the part of the recipient, often discussed as a matter of "allowing the individual to be their true self." But these factors are superficial. Consent is obviously important, but it does not automatically make the thing being consented to good, for it is possible to consent to something bad. Here is one example: if a stuntman agrees to be set on fire and happens to pay the price for his risk-taking with first-degree burns, then he consented to something wrong, since his choice resulted in self-destruction (unless self-destruction is not wrong, which sounds preposterous). It may be objected that the stuntman did not consent to first-degree burns, but rather, to simply being set on fire. But surely it must be admitted that first-degree burns are a possible consequence of being set on fire. To make a primary agreement to the latter is to make a secondary agreement to the former.

Much of the same could be said about desire. But whereas consent merely agrees, desire wants. It is not out of the question that someone can want something that is not good. Indeed, basic human desires often produce appalling consequences. Sexual desire, when let loose from its proper restraints, results in debauchery. A desire like hunger, as well, is meant to motivate someone to nourish their body; yet the desire for food can easily move someone towards excess, resulting in gluttony. There is nothing about desire per se that is right or wrong, for it is morally neutral. What matters is the value of that which desire aims at.

It is time to bring this blog post to a close. I admit that I have a shtick just as much as those I argue against. However, based on the evidence before me and my own theoretical reflections, I find popular sentiments about gender-affirming care to be found wanting. This does not mean that I have the final word. But those who endorse the gender-affirming paradigm are not infallible either. 

Are sex and gender truly ontologically separate categories? Is it right for someone to identify in a way that does not correspond to their body, especially to the point of undergoing surgery? These are the questions anyone with an opinion on the topic must come to terms with, and they are not silly questions. This is a matter of parsing out what someone has a choice about and what they do not, for there are some things that humans are simply born with or situated in, such as one's parents and place of birth. Should the same be said about sex/gender or not?

Perhaps many gender-affirming advocates are motivated by compassion. But compassion, when separated from critical thinking, can quickly lead to irresponsible permissiveness. The highest good that liberalism offers is allowing people to do whatever they want so long as they consent to it and it is not "harmful." What is better is a society composed of citizens who take time to think about what is true and right, and to live those values out.