By Ryan T. Anderson
Originally published November 2018
Why should a doctor perform surgery when it won’t make the patient happy, it won’t accomplish its intended goal, it won’t improve the underlying condition, it might make the underlying condition worse, and it might increase the likelihood of suicide? Sound medicine isn’t about desire, it’s about healing.
In Sunday’s New York Times, Andrea Long Chu writes a heartfelt and heartbreaking op-ed on life with gender dysphoria. Titled “My New Vagina Won’t Make Me Happy,” the op-ed reveals painful truths about many transgender lives and inadvertently communicates almost the exact opposite of its intended argument.
Next week, Chu will undergo vaginoplasty surgery. Or, as Chu puts it: “Next Thursday, I will get a vagina. The procedure will last around six hours, and I will be in recovery for at least three months.”
Will this bring happiness? Probably not, but Chu wants it all the same: “This is what I want, but there is no guarantee it will make me happier. In fact, I don’t expect it to. That shouldn’t disqualify me from getting it.”
Chu argues that the simple desire for sex-reassignment surgery should be all that is required for a patient to receive it. No consideration for authentic health and wellbeing or concern about poor outcomes should prevent a doctor from performing the surgery if a patient wants it. Chu explains: “no amount of pain, anticipated or continuing, justifies its withholding.”
This is a rather extreme conclusion. Chu writes: “surgery’s only prerequisite should be a simple demonstration of want.” This is quite a claim. And we’ll come back to it. But as the op-ed builds to this stark conclusion, Chu reveals many frequently unacknowledged truths about transgender lives—truths that we should attend to.
Sex Isn’t “Assigned,” and Surgery Can’t Change It
First, Chu acknowledges that the surgery won’t actually “reassign” sex: “my body will regard the vagina as a wound; as a result, it will require regular, painful attention to maintain.”
Sex reassignment is quite literally impossible. Surgery can’t actually reassign sex, because sex isn’t “assigned” in the first place. As I point out in When Harry Became Sally, sex is a bodily reality—the reality of how an organism is organized with respect to sexual reproduction. That reality isn’t “assigned” at birth or any time after. Sex—maleness or femaleness—is established at a child’s conception, can be ascertained even at the earliest stages of human development by technological means, and can be observed visually well before birth with ultrasound imaging. Cosmetic surgery and cross-sex hormones don’t change biological reality.
People who undergo sex-reassignment procedures do not become the opposite sex—they merely masculinize or feminize their outward appearance.
Gender Dysphoria Is Deeply Painful
Second, Chu acknowledges the deep pain of gender dysphoria, the sense of distress or alienation one feels at one’s bodily sex:
Dysphoria feels like being unable to get warm, no matter how many layers you put on. It feels like hunger without appetite. It feels like getting on an airplane to fly home, only to realize mid-flight that this is it: You’re going to spend the rest of your life on an airplane. It feels like grieving. It feels like having nothing to grieve.
“Transitioning” May Not Make Things Better and Could Make Them Worse
Third, Chu acknowledges that “transitioning” may not make things better and could even make things worse. Chu writes: “I feel demonstrably worse since I started on hormones.” And continues: “Like many of my trans friends, I’ve watched my dysphoria balloon since I began transition.”
Indeed, as I document in When Harry Became Sally, the medical evidence suggests that sex reassignment 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.
Even the Obama administration admitted that the best studies do not report improvement after reassignment surgery. In August 2016, the Centers for Medicare and Medicaid wrote: “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].”
What does that mean? A population of patients is suffering so much that they would submit to amputations and other radical surgeries, and the best research the Obama administration could find suggests that it brings them no meaningful improvements in their quality of life.
Suicide Is A Serious Risk
Fourth, Chu acknowledges a struggle with suicide ideation: “I was not suicidal before hormones. Now I often am.”
In 2016, the Obama administration acknowledged a similar reality. In a discussion of the largest and most robust study on sex-reassignment, the Centers for Medicare and Medicaid pointed out “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).”
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. Indeed, the Obama administration noted 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.
The Purpose of Medicine Is Healing
This brings us back to Chu’s argument that “surgery’s only prerequisite should be a simple demonstration of want.” What should we make of it?
Why should a doctor perform surgery when it won’t make the patient happy, it won’t accomplish its intended goal, it won’t improve the underlying condition, it might make the underlying condition worse, and it might increase the likelihood of suicide? Chu wants to turn the profession of medicine on its head, transforming a medical doctor into nothing more than “a highly competent hired syringe,” in the words of Leon Kass.
Unfortunately, Chu isn’t alone. Many professionals now view health care—including mental health care—primarily as a means of fulfilling patients’ desires, whatever those are. Kass explains:
The implicit (and sometimes explicit) model of the doctor-patient relationship is one of contract: the physician—a highly competent hired syringe, as it were—sells his services on demand, restrained only by the law (though he is free to refuse his services if the patient is unwilling or unable to meet his fee). Here’s the deal: for the patient, autonomy and service; for the doctor, money, graced by the pleasure of giving the patient what he wants. If a patient wants to fix her nose or change his gender, determine the sex of unborn children, or take euphoriant drugs just for kicks, the physician can and will go to work—provided that the price is right and that the contract is explicit about what happens if the customer isn’t satisfied.
This vision of medicine and medical professionals gets it wrong. Professionals ought to profess their devotion to the purposes and ideals they serve. That’s what makes them professionals, and not just service providers. Teachers should be devoted to learning, lawyers to justice under law, and physicians to “healing the sick, looking up to health and wholeness.” Healing is “the central core of medicine,” Kass writes—“to heal, to make whole, is the doctor’s primary business.”
But Chu’s vision of medicine turns the doctor into someone who merely satisfies desires, even if what is done isn’t good for a patient. Chu writes:
I still want this, all of it. I want the tears; I want the pain. Transition doesn’t have to make me happy for me to want it. Left to their own devices, people will rarely pursue what makes them feel good in the long term. Desire and happiness are independent agents.
Sound medicine isn’t about desire, it’s about healing. To provide the best possible care, serving the patient’s medical interests requires an understanding of human wholeness and well-being. Mental health care must be guided by a sound concept of human flourishing.
Our brains and senses are designed to bring us into contact with reality, connecting us with the outside world and with the reality of ourselves. Thoughts and feelings that disguise or distort reality are misguided, and they can cause harm. In When Harry Became Sally, I argue that we need to do a better job of helping people who face these struggles.
Misrepresentations of My Work
And Chu takes issue with me:
Many conservatives call this [gender dysphoria] crazy. A popular right-wing narrative holds that gender dysphoria is a clinical delusion; hence, feeding that delusion with hormones and surgeries constitutes a violation of medical ethics. Just ask the Heritage Foundation fellow Ryan T. Anderson, whose book “When Harry Became Sally” draws heavily on the work of Dr. Paul McHugh, the psychiatrist who shut down the gender identity clinic at Johns Hopkins in 1979 on the grounds that trans-affirmative care meant “cooperating with a mental illness.” Mr. Anderson writes, “We must avoid adding to the pain experienced by people with gender dysphoria, while we present them with alternatives to transitioning.”
Of course I never call people with gender dysphoria crazy. And I explicitly state in the book that I take no position on the technical question of whether someone’s thinking that he or she is the opposite sex is a clinical delusion. That’s why Chu couldn’t quote any portion of my book saying as much.
Throughout the book, I point out that the feelings that people who identify as transgender report are real—they really feel a disconnect with their bodily sex—but I also acknowledge the fact that those feelings don’t change bodily reality. I recognize the real distress that gender dysphoria can cause, but never do I call people experiencing it crazy.
I repeatedly acknowledge that gender dysphoria is a serious condition, that people who experience a gender identity conflict should be treated with respect and compassion, that we need to find better, more humane and effective, responses to people who experience dysphoria.
Nevertheless, Chu claims that I am engaged in “‘compassion-mongering,’ peddling bigotry in the guise of sympathetic concern.”
For the record, Chu never contacted me regarding my research or my book. Nor did the Times contact me to verify any of the claims made about me in the op-ed. Indeed, this is the second time the New York Times has published an op-ed with inaccurate criticisms of me and my book.
Americans disagree about gender identity and the best approaches to treating gender dysphoria. We need to respect the dignity of people who identify as transgender while also doing everything possible to help people find wholeness and happiness. That will require a better conversation about these issues, which is why I wrote my book. And it’s presumably why Chu wrote this op-ed. Now is not the time for personal attacks and name-calling, but for sober and respectful truth-telling.
Chu may regard me as a “bigot,” but I regard Chu as a fellow human being made in the image and likeness of God who is struggling with a painful and dangerous condition. As such, Chu deserves care and support that will bring health and wholeness—not the on-demand delivery of “services” that even Chu acknowledges are unlikely to make life better and may make it very much worse.