Clueless

This has got to break some sort of record for stupid.

Yesterday, I heard a man equate the sacrifices made by Thomas Beatie so that he and his wife could have children, with the crowd of idiots who trampled a man to death so they could get inside a Wal-Mart to go shopping. No kidding, this was on (OMG!) “Janet Parshall’s America” (see here for more on that). The man is named Wesley J. Smith, and he writes a blog about bioethics and “the importance of being human.” Bioethics is a big subject, and Wesley J. Smith may well have something insightful to say about some aspect of it, for all I know. But that possibility now seems remote to me, given that he knows so little and displays absolutely no inquisitiveness about something as central to being human as gender.

Here is the “reasoning” involved in his placing those two completely opposite events in the same category, something he calls “coup de culture“: He thinks they are both illustrations of “hedonistic people” who are self-centered and think they should get what they want when they want it, no matter what it takes. He may have a point with the Wal-Mart shoppers; as I recall, they refused to stop shopping even after learning that they had trampled a man to death. However, I’m having a hard time understanding how Mr. Beatie could possibly be viewed as “hedonistic” after not only experiencing the rather harrowing and difficult process of gender transition, but then reversing that process so that he and his wife could have a child together. That strikes me as a tremendously loving act of self-sacrifice, and quite the opposite of hedonism. Such a peculiar misreading is only explicable if Smith’s understanding of gender and of transsexual people is belligerently cartoonish.

I don’t wish to be unfair. Not understanding what gender identity is, not being familiar with the lives of any transsexual people, or with the science associated with that particular medical condition, is not something about which anyone needs to be ashamed. There are probably a lot of folks who don’t know anything about transsexual people – but most of them don’t write multiple blog entries on this subject about which they have no knowledge. Smith does, so he has invited this:

Congratulations, dude! You’re clueless.

In reading over his blog, I see that Smith feels that transsexual people are suffering from an “emotional confusion,” a meaningless term that no clinician would ever use to describe this condition. To his credit, he does manage to get one thing right, by admitting in a comment to one of his posts that “this is definitely not my area of expertise.” Also to his credit, he voices a desire to have “compassion” for those so afflicted. Unfortunately, while compassion is very important, it is neither a substitute for knowledge, nor an excuse for paternalism.

Smith’s primary objection seems to be that the existence and visibility of transsexual people has resulted in the definition of gender as “a subjective, internal state,” a false understanding of gender identity that has been promoted repeatedly by small-minded political campaigns to legalize discrimination, such as the one recently defeated in Montgomery County, MD. The notion that a person just “decides” to be a man or a woman on a whim, perhaps just for the day, appears prominently in the messaging of such campaigns, incongruously side by side with the notion that transsexual people are afflicted with a tragic mental delusion. While the first one does indeed sound hedonistic, neither of these ideas is accepted as true within mainstream medicine.

There once was a medical theory that gender identity is just a subjective, internal state; it was primarily articulated in the 1960’s and 70’s by Dr. John Money, a researcher at Johns Hopkins University. The thinking then was that gender identity is the product of rearing and socialization, and is not biologically determined. This theory was demonstrated to be spectacularly wrong, most famously by the case of David Reimer, who had the misfortune of becoming Money’s perfect experimental subject. Many others, people born with visible intersex conditions who were wrongly “assigned” a gender based on the convenience of a surgeon, have eloquently debunked this theory as well. We now know better. Sometimes medicine gets it wrong. What matters is the ability to learn, synthesize emerging knowledge, and start getting it right.

The point of this is that it’s now generally accepted that gender identity is biological, determined by events during prenatal development (see, for instance, the work of Reiner and Gearhart). The brain is of course a biological organ just as “real” as any other part of the body. Being raised as a girl and forced to ingest estrogen pills could do nothing to change David Reimer’s neurology to female. This is equally true for everyone else, whether they are transgender or cisgender: No amount of gendered rearing, behavioral modification, punishment, or other approaches designed to conform the subjective mind to a desired outcome can do anything to alter a person’s basic neurological gender.

That’s why the treatment protocol for Gender Identity Disorder, misplaced by circumstances of history in a manual of mental disorders, is entirely medical. Medical disorders, once diagnosed, are treated with medical therapies. In this case, the treatment involves reducing, to the extent possible, the misalignment between different biological markers of gender: Neurological “wiring,” which is not subject to alteration, and other biological markers, which are. In a further demonstration that we are describing a medical, not mental, disorder, the process of differential diagnosis for GID requires a clinician to explicitly eliminate the possibility of psychosis or the kind of mental delusions that accompany body image disorders such as anorexia.

Smith, believing gender identity to be a figment of the imagination in opposition to the realness of “biology” and “the body,” might as well be writing in the 1950s, or even the Victorian era, so limited is his knowledge. He would, I suspect, argue that the David Reimer case is completely different from both intersexual people who have been wrongly assigned, and transsexual people who choose medical transition (and there is significant overlap between these groups), because David Reimer was born a “normal” male. This deliberately misses the point of what gender identity is. If, as is now becoming clear, gender identity is biologically determined, it is only one of several markers of biological gender, including internal reproductive organs, external genitalia, chromosomes, etc., any of which may differentiate prenatally in a way that is incomplete or incongruent with other markers. The idea that the misalignment of only one of these markers must be concurrent with some other incongruity in order to be “real” makes no sense and has no basis in medical science.

It is also arbitrary and capricious, and seems more driven by political and ideological concerns than by ethical ones. One of the most peculiar things about veiwpoints like Smith’s is the easy slippage between absolute biological determinism with regard to gender (in, for instance, the insistence that men and women are inherently, irreducibly different creatures, because their brains are biologically different), and the absolute denial that transsexual people could have biologically gendered brains that differentiated opposite the rest of their bodies. It is, as they say, a puzzlement.

There are other puzzling things here as well. Since he has written sneeringly about an emerging protocol for the treatment of some gender variant kids (temporarily blocking the wrong puberty, with it’s permanent effects, until they reach the age of consent), treating this humane intervention as an ethical crisis, why is it that I can’t find any criticism on his blog of the genuinely harmful practice of “intentionally creating unhealthy bodies” I refer to above, the permanent genital mutilation of intersexual children for social and cosmetic reasons? As far as I can tell, Smith has never even addressed this horrific practice, in which not only is consent impossible, but a recommended part of the treatment is to lie to the patient about his/her medical history. In what twisted universe would such abuse not be an issue of medical ethics?

Meaningful discussion of a bioethics issue, whether it’s stem cell research, the question of when life begins and ends, or the agency of people to make decisions about their own bodies, requires a competent understanding of the science involved. Why does Smith try to pass himself off as a bioethics expert if he’s relying on a popular folk understanding of gender instead of the complex science? And why, when he admitted nearly a year ago that he has no expertise in this area, does he continue to expound on the topic of gender transition having done nothing to further educate himself?

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