I have argued that the desire for sexual identity is one of the 20 natural desires of our evolved human nature. If so, does that provide any natural standard for adjudicating the debate over transgender equality? Most human beings easily identify their biological sexual identity as male or female. But in a few cases, men desire to identify themselves as women, or women desire to identify themselves as men. Does this show that gender identity is a social construction or mental experience that has nothing to do with the biological sex of the body? Must we respect this gender identity by treating transgender women as women and transgender men as men?
So, for example, must we allow Caster Semenya to compete in the Olympics as a woman, even though she is a chromosomal male (XY) with the high testosterone levels typical for men, which gives her an advantage over other women in running events? If we allow this, this would probably mean that chromosomal women (XX) will almost never win in Olympic running events competing with transgender or intersex women like Semenya.
Under present rules, Semenya will be prohibited from defending her 800m gold medal (won at the 2016 Summer Olympics in Rio de Janeiro), unless she takes drugs to reduce her testosterone to typically female levels. Two days ago, her lawyers announced that they will be appealing to the European Court of Human Rights to ask that they overturn this rule as a violation of her human rights.
In a previous post, I have written about the controversy over Semenya, arguing that the science of sexuality confirms what we should know by common-sense experience that both the norm of sexual duality and the few exceptions to that norm are biologically real, and not just arbitrary social constructions. We can respect Caster Semenya as an intersex individual with a partially male body and a female gender identity. But we must also respect those many typically female athletes who want to compete with other biological females, so that they have a chance to display their athletic excellence. To resolve this conflict of interests, the Olympic committees have properly ruled that intersex individuals like Semenya must either compete with men or reduce their testosterone levels to compete with women.
A similar dispute has arisen in the debate over the Equality Act, just passed by the House of Representatives, which would amend the Civil Rights Act of 1964 to prohibit discrimination on the basis of both sexual orientation and gender identity. By passing this legislation, the Congress would endorse the interpretation of the Civil Rights Act adopted by the Supreme Court last summer in the Bostock case, where Neil Gorsuch (a Trump appointee) wrote the majority opinion that rejected the Trump Administration's claim that the sexual equality of men and women under the Civil Rights Act does not include the equal treatment of gays and transgender people. I have written about this here and here.
President Biden has nominated Dr. Rachel Levine to be assistant secretary of health, who would be the first openly transgender federal official confirmed by the Senate. In the first confirmation hearing, Senator Rand Paul questioned her about whether she supported genital mutilation, gender reassignment surgery, and hormone therapy for children. Levine was evasive, replying that, "Transgender medicine is a very complex and nuanced field with robust research and standards of care."
Apparently, Paul's questioning was motivated by reports that Levine has endorsed a research study concluding that doctors should provide drug therapy for transgender adolescents to suppress puberty, because this would improve their mental health by bringing the sexual traits of their bodies into harmony with their transgender identity. The study was published in the journal Pediatrics--"Pubertal Suppression for Transgender Youth and Risk of Suicidal Ideation," 145 (February 2020): e20191725.
Transgender people are known to suffer from high rates of suicidal thoughts--with about 40% having attempted suicide. The claim of this new study is that pubertal suppression for transgender children would reduce this propensity to suicide, which would show better mental health for them. This would be done by doctors prescribing gonadotropin-releasing hormone analogues that suppress puberty for adolescents 9 to 16 years old.
The method in this study was to conduct a survey of 20,619 transgender adults aged 18 to 36 years old, who were asked about their history. Of this group, 3,494 individuals reported that they had at some time wanted to have puberty suppression therapy, but only 89 of these individuals reported that they had actually had the treatment. These individuals were also asked about whether they had ever had suicidal thoughts or whether they had attempted suicide. The researchers were able to show that those who reported receiving the puberty suppression treatment had a lower rate of suicidal thoughts and attempts than those who wanted the treatment but did not receive it. The researchers concluded: "pubertal suppression for transgender adolescents who want this treatment is associated with favorable mental health outcomes." And this is the conclusion that has been widely reported in the news media.
But if you read this study carefully, you will see some dubious features of their reasoning. First of all, there's the fundamental methodological problem with all such survey research: they rely totally on the self-reporting of the people surveyed, although it is well known that people are often not accurate or honest in reporting what they have done or believed (see George Beam, The Problem with Survey Research, Transaction Publishers, 2014).
For instance, when some individuals report that they have had pubertal suppression treatment, and consequently they became less suicidal than they would been without the treatment, how do we know that this is true? The research collected no medical records or observational data to confirm this self-reporting. People who would report that they remained suicidal even after having the treatment would be confessing that their beliefs and behavior were mistaken. Is it possible that they might be reluctant to admit that (even to themselves)?
Moreover, if you look at the actual raw numbers, they do not provide strong support for the conclusions of the article. Only 16.9% of the people surveyed reported that they ever wanted pubertal suppression, so it seems that the great majority of transgender people do not believe this treatment would be good for them. And those who actually received the treatment were only 0.43% of the total!
Of those who reported wanting to have the treatment, only 89 individuals (2.5%) reported that they had actually had the treatment. And of those 89, 67 (75.3%) reported that they had thought about suicide, while 37 (41.6 %) reported attempting suicide. 41.6% attempting suicide is close to the 40% of transgender people generally who attempt suicide. It's hard to see that the treatment has done them much good.
Now, it is true that those who reported wanting the treatment but not having it have a higher rate of suicidality than those who wanted it and had it. But the differences are not very dramatic. Of the first group, 90.2% report suicidal thoughts, and 51.2% reported attempts at suicide--as compared with 75.5% and 41.5%, respectively, for the second group.
The most striking finding in these numbers is that regardless of whether transgender people report having puberty suppression or not, transgender people as a whole suffer depressingly high rates of suicidal behavior, much higher than for the general population.
There's another problem here. Those who had puberty suppression treatment between the ages of 9 and 16 were minors. That means that their parents agreed to this. Did the parents force or coax their children into doing this? Weren't these children too young to make a mature decision of this sort on their own?
Why shouldn't the law prohibit children and parents from making this decision until the children are young adults with enough moral and intellectual maturity to make this decision for themselves?
A popular explanation of transgender people is that they feel "trapped in the wrong body." These people are said to have a personal gender identity that conflicts with the biological sexual identity of their bodies, and so they might seek hormonal and surgical treatment to change the sexual identity of their bodies to conform to their gender identity. It has now become a standard medical treatment for "gender dysphoria" to provide procedures for changing one's sex to coincide with one's preferred gender, so that men can become women, and women can become men.
I agree with Melissa Moschella (a philosopher at Catholic University of America) who has argued against this "wrong body" narrative as based on a false dualist view of human nature that should be rejected in favor of an "animalist" view. Dualism is false because the body is intrinsic to our personal identity. Animalism rightly sees that our personal sexual identity as male or female is rooted in the biological identity of our body. We are our animal bodies. And therefore men are those with male bodies, and women are those with female bodies. It's impossible to change one's biological sex, because biological sex is impressed on our body and brain early in fetal and neonatal life.
Gender dysphoria, she has argued, is not a medical problem requiring physiological or surgical treatment but a psychological problem requiring psychiatric counseling. Those with gender dysphoria are suffering from the mental delusion that their mental sexual identity differs from the sexual identity of their body. So doctors who try to help them undergo a biological sex change are not curing them but rather supporting their delusional disorder. This explains why although patients often feel better initially after sex-change procedures, later on they often become depressed, anxious, and suicidal.
Moschella makes a comparison with anorexia. The cure for anorexia is not liposuction, although the patient might initially feel better, because the problem is not obesity but the psychological delusion of being too obese.
Moschella has also pointed out the incoherence in the "wrong body" idea. It is said that a person's gender identity is in the mind not in the body. But then it is said that the sex of the body must be changed to be in harmony with the true gender identity of the person, which concedes that the sex of the body really is essential for sexual identity.
Moschella seems to be agreeing with Dr. Paul McHugh at Johns Hopkins University Hospital, who was responsible for shutting down the sex-change treatment program that had once been supervised by Dr. John Money. Money was the one who invented the idea of "gender identity" as different from "sex identity," with the thought that "gender" is a mental or social construction that need not conform to biological nature. This has supported the claim that while animals have "sex," only humans have "gender." Moschella's animalism seems to deny the gender/sex dichotomy started by Money.
It should be said, however, that biological nature does sometimes throw up anomalous cases that cannot be clearly identified as male or female--the most obvious case being those who are born as true hermaphrodites, who combine male and female traits. In response to a question about such cases of intersexuality, Moschella has conceded that these cases show a biological disorder creating confusion about biological sex identity, but gender dysphoria is not an intersexual anomaly of nature like this.
For Moschella to sustain this claim, she would have to refute the "developmental mismatch" theory of gender dysphoria. According to this theory, in utero the sexual differentiation of the genitals occurs separately and earlier than the sexual differentiation of the brain, so that it is possible for the sexual identity of the body to differ from the sexual identity of the brain. This is not a dualist theory that denies animalism, because both the body and the brain are biological realities of the human animal.
My argument here is that the central tendency of animal biology is to distinguish the sexual identity of males and females as determined by their complementarity for reproduction. But while this holds for the most part, there are exceptional cases in nature where the bipolarity of male and female becomes confused.
Some of my other posts on intersexuality and gender dysphoria can be found here, here, and here.