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Lost In Trans–lation: The Enormous Problem of Agenda-Driven Research

A law professor in Canada recently published a piece expressing concern regarding the current standard practice of requiring persons to obtain a psychological assessment prior receiving hormone replacement therapy (“HRT”) or genital surgery. 

This practice has been one of the Standards of Care [1] (“Standards”) advocated for years by the World Professional Association for Transgender Health (WPATH), an organization whose published vision statement reads:  “We envision a world wherein people of all gender identities and gender expressions have access to evidence-based healthcare, social services, justice and equality.”  Clearly, this organization is not ever going to be accused of discriminating against persons who claim to be of a different gender than their birth sex. 

Among other criteria, the Standards state: “If significant medical or mental concerns are present, they must be reasonably well controlled.”  In this, the purveyors of the Standards are recognizing that persons who are distressed by their birth sex identity may well struggle with a range of mental health concerns [2] including anxiety, depression, self-harm [2], a history of abuse and neglect, compulsivity, substance abuse [2], sexual concerns, personality disorders, eating disorders, psychotic disorders, and autistic spectrum disorders [3].  The document also asserts that “[t]he role of mental health professionals includes making reasonably sure that the gender dysphoria is not secondary to, or better accounted for, by other diagnoses;” and further, “[t]hese concerns can be significant sources of distress and, if left untreated, can complicate the process of gender identity exploration and resolution of gender dysphoria.”

Despite WPATH’s clear advocacy for normalizing gender dysphoria, as far as it goes, these standards appear to recognize the need to address any emotional or psychological disorders which may underlie a desire to seek sex reassignment surgery.  However, it should be again noted, that in order to be an informed consumer of research on issues related to LGBT persons, one must recognize that the implicit assumptions of some researchers, and the politicization of some journals, will leave one confused regarding what the science actually says. 

For example, the WPATH document clarifies that the host of psychological and emotional concerns might be “related or unrelated to what is often a long history of gender dysphoria and/or chronic minority stress.”  In other words, the myth that persons who experience themselves as a gender other than their birth sex would be well-functioning persons if it weren’t for the discrimination and lack of social acceptance they receive, is well ensconced as the starting point of all discussion.  Yet, there is solid evidence [4] that persons who feel that they would be more content in life if they lived as the other sex, have some foundational issues that need and deserve compassionate, caring treatment based upon the truth of how they were born. 

What’s The Concern?

The author of the lead article begins thusly: “When I decided that I wanted to take hormones to feminize my body, the last thing I wanted to do was to go in front of a psychologist to justify my decision.”  Granted, this was published in the “Viewpoint” section of the Journal of Medical Ethics, and the author later moved towards more professional and ostensibly logical rhetoric, yet the lack of objectivity remained, and regularly wafted into the article.  For example, evidence of the long-term dangers [5] of transitioning to a different sex, such as escalating suicidality, are ignored. 

The author’s main point is one of self-determination, arguing that requiring the medical community to weigh in on what is perceived to be an autonomous decision is “dehumanizing and unethical.”  Drawing an analogy to the decision to procure an abortion, the author notes: “We do not typically think that it is ethical to require psychological evaluations prior to abortions…. [N]either pregnancy nor being trans is an illness.” 

The alternative plan put forth is based on an informed-consent model, where the person would not be evaluated, but rather told of the “potential benefits, risks and limitations” of procedures to aid the decision-making process.  From a medical perspective, informed consent is an essential and non-negotiable component of any therapeutic intervention, as it allows the patient to have control and choice regarding if and when to access a particular treatment.   However, the reliability of the information provided is typically not as fraught with controversy and agendas as is the case for some diagnoses within the current psychiatric diagnostic manual [6]—in particular, the linguistic shift from Gender Identity Disorder to Gender Dysphoria.

This shift moves the determination of person’s gender identity from observable, biological evidence, to a person’s feelings about him- or herself.  However, even in this more emotive framework, I think it is professionally responsible both to inform a patient of the long-term risks of going through HRT or surgery, and the near-term need for treatment of any underlying issues.  The author’s desire to limit the process to the purely subjective element, is not only dangerous for those who are seeking help, but also fails to respect their dignity by affording them the best guidance science has to offer.