"First, do no harm" ( Primum non nocere) is the first ethical axiom all medical students are taught. It takes many years to fully internalize what that means, from learning to respect the patient's determination of harm to himself, to the restraint a surgeon must exercise when she wants to clip off just a wee bit more tissue to leave a more elegant result (having learned that there may be an arteriole hiding in the tissue which she does not want to cut lest bright red blood spatter everyone within reach).
For physicians who write for a living or avocation, particularly those who write for a globally respected newspaper like The New York Times, the dictum is even more important, as the impact is not limited to just one person but will potentially affect many. It's even more important when that physician is an academic psychiatrist, such as The Times' new science writer, Richard A. Friedman of Cornell Medical College.
Dr. Friedman, a specialist in mood disorders but not human sexuality or sexual development, let loose an op-ed in The Times last week entitled, "How Changeable Is Gender?" The short answer is, "Gender identity is fixed by age four and unchangeable; gender expression often changes on a daily basis." But the good doctor didn't bother to learn his basic definitions.
I responded on HuffPo Live, and now in print. The Times should have fact-checked Dr. Friedman, who made a gross mistake early on when he stated that transsexualism is very rare, of the order of 5/100,000. When I saw that prevalence ratio, which was derived from long outdated data from the days trans persons were universally treated as sexual deviants, I knew we were in for trouble (the best estimate is 3/1000, a factor of 100 larger). It was unfortunate because he had started well, with a positive tone and promotion of new brain scan data from Georg Kranz of the Medical University of Vienna. Many of us had been waiting for years for the development of this new breed (diffusion tensor) of high-resolution MRI scans, because the classical work done two decades ago was done on neuropathology specimens, and no one wants to die to help advance medical science.
The result was in line with all the older research and confirmed our expectations -- trans persons had brain structures consistent with their gender identity, or their brain sex, and not with the sex assigned them at birth based on genitalia. Great!
The results even showed a spectrum, consistent with the spectrum of gender identities as experienced by persons, young and old. But rather than celebrate with the trans community, particularly with us physicians and scientists who've been trumpeting similar earlier results for decades, he compared trans persons to gay ones (for whom there is no equivalent scientific evidence of unique brain function, by the way), acknowledged that reparative therapy for gay people is a dismal failure, and then asks, "What do we really know about how happy transitioned trans persons are?" Clearly they're not crazy, he acknowledges, and while we have to accept gay people and not attempt to change them, must we do the same with trans persons? Doesn't biology put constraints on a person's realization of her gender identity?
It's obvious that he answers that last question in the affirmative, and to such a degree that he questions the utility of gender transition and genital surgeries. He goes research shopping and then misreads data to fit his pre-existing conclusion.
News flash -- there is no longer any debate within the medical community on whether transition and medical and surgical care, when desired by the person, is helpful. It is. The American Medical Association, American Psychological Association, American Psychiatric Association, American Academy of Pediatrics and the World Professional Association for Transgender Health, unanimously agree. All studies since the '90s show patient satisfaction rates around 97-98 percent. There are few other surgical procedures, outside of cataract surgery, with that kind of positive response. The only academic debate that remains is situated in the realm of trans children, and that window is fast closing as the global center of trans reparative therapy in Toronto, the infamous Clarke Institute (Centre for Addiction and Mental Health), is under attack. Team Freud -- Drs. Zucker, Bailey, Blanchard, Lawrence, Vilain, Dreger and now Friedman -- which sees perversion in all trans women, is fighting its last ditch effort, as evidenced by the recent resignation of their cheerleader, Alice Dreger, author of Galileo's Middle Finger, from Northwestern University.
The problem with this ongoing debate comes down to nomenclature. First, you must distinguish gender identity from gender expression. We all have a gender identity, and we all express our gender in very personal ways. Trans persons who transition gender with surgical reconstruction are the outliers who exemplify one end of the spectrum -- we bring our bodies in line with our brains, and then live according to society's gender norms, to one degree or another. Those who transition socially but not surgically provides better evidence of the distinction between identity and expression, as the physical does not match up to society's definition of sex but the expression does. Many people with severe gender dysphoria obtain total relief from transition -- the dysphoria is cured. But if society is still hateful and overt in its discrimination, the anguish remains, or may increase, thereby increasing the risk of suicide for some.
The numbers from the Karolinska study, which apply primarily to those who transitioned prior to 1989 (the Middle Ages for trans persons), are bogus. You cannot compare trans women who undergo surgery with cisgender women, and use the differential suicide rates to tell you anything useful. Your control group must be trans women, and not just any such women, but trans women who want surgery but are refused it. Then the suicide differential is relevant and useful, but such a study would be grossly unethical.
Friedman's second nomenclature problem lies in defining gender dysphoria, and how you distinguish the trans kids from the gender non-conforming ones. Here I need to highlight the issue that underlies this debate, and has fueled the decades of hostility towards trans women of all ages -- misogyny.
First, there is no debate about trans boys, or gender non-conforming girls. Not for Friedman, nor for his allies who routinely blithely write off the existence of trans boys because it totally undermines their theories of transgender people being either confused boys, conflicted gay men or sexually deviant straight men.
So we're left with the boys who misbehave by behaving like girls. Admittedly there is no fail-safe way to distinguish the trans girls from the future gay boys, but those working in the field can get a pretty good handle on it. When a child tells you she's a girl and simply wants to be a regular girl, however that manifests for her in her particular environment, you assume she's trans. If he doesn't, he's probably gay (yes, gay men were once gay boys, and often exhibit behavior in their youth that is gender variant), or maybe straight. Gay boys like their penises. And by simply allowing children to be themselves, and doing nothing surgically until maturity and nothing medically other than reversibly delaying or ultimately preventing the wrong puberty, you allow those children to develop in a supportive gender-appropriate environment. Trans girls suffer gender dysphoria being raised as boys; feminine and gay boys do not, and just want to express themselves in a gender variant manner.
I say it plainly -- forcing a trans girl to live as a boy, and then to undergo a male puberty, is cruel and unusual punishment. There is no excuse for it, other than the shame and discomfort the parents may feel, rooted in the misogyny of a society that just can't conceive of any man wanting to give up his penis.
No man wants to give up his penis. But trans girls, with penises, are not males. They're females. So there is no surprise at all once you understand that. If it helps, picture Eowyn of Rohan confronting the Witch King of Angmar on the Pellenor Fields (The Lord of the Rings, Vol. III -- The Return of the King), who bellows at her, "No living man may hinder me." Eowyn replies, "I am no man!" That's how trans women feel when asked how we felt when we were men.
What's the downside of supportive care? The possibility that some gay boys may live as girls until they desist and revert to living as gay boys. Will they be overwhelmed by shame? Unlikely. Their parents? Maybe, but not that important. In the meantime, the trans girls grow and develop as their brains direct. First, do no harm. Just care about the girls as much as you care about the boys, who aren't as fragile as you imagine.
Friedman, as part of a shrinking clique of Freudians -- whom I call the "resisters" -- based in Toronto, view the trans experience through the lens of sexuality rather than biological identity. To them, trans women do not exist -- they are either repressed gay men or perverted straight ones. They are unable to get with the overwhelming consensus and reject their life's work and the social networks they've built around it. Their efforts today are to cry that since "there are no randomized clinical trials and very few comparative studies examining different approaches for this population," we should leave these children to suffer. The reality is that medicine rarely is based on expensive and difficult randomized clinical trials, and no such study has been performed on trans persons for 25 years for political and ethical reasons, and we still generally do quite well, thank you. The profession has come to see trans persons as human; it's time the holdouts do so as well.
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