We argue that “gender affirmation” procedures violate sound medical ethics, that it is profoundly unethical to reinforce a male child in his belief that he is not a boy (or a female child in her belief that she is not a girl), and that it is particularly unethical to intervene in the normal physical development of a child to “affirm” a “gender identity” that is at odds with bodily sex. Childhood and adolescence are difficult enough as it is. Adults should not corrupt the social ecology in which children develop a mature understanding of themselves as boys or girls on the pathway to becoming men or women.
Rather than teaching children to identify based on how well they fit prevailing cultural expectations on sex, we should be teaching them that the truth of their sexual identity is based on their bodies, and that sometimes cultural associations attached to the sexes are misguided or simply too narrow. There is a wonderfully rich array of ways of expressing one’s embodiment as male or female.
Several weeks ago, many Americans were concerned about a seven-year-old boy in Texas who was the subject of a custody battle after his parents divorced. Fights over the custody of children are always tragic, but what made this one especially disconcerting was that the parents disagreed about medical care for their son. This wasn’t just any usual medical decision for a child, where parents need to consider the treatment options and weigh the respective likelihoods of success, potential side-effects, and risks. No, this was a case where the parents favored radically different treatment options because they disagreed about the identity—the “gender”—of their little boy. One of the parents believes the child is actually a girl, a girl trapped in a boy’s body.
It was this disagreement that led to the bitter battle over treatment. So, without saying anything specific about this child’s case, we want to offer readers our best take on what is at stake: the anthropology, ideology, and ethics at issue.
We argue that “gender affirmation” procedures violate sound medical ethics, that it is profoundly unethical to reinforce a male child in his belief that he is not a boy (or a female child in her belief that she is not a girl), and that it is particularly unethical to intervene in the normal physical development of a child to “affirm” a “gender identity” that is at odds with bodily sex. Childhood and adolescence are difficult enough as it is. Adults should not corrupt the social ecology in which children develop a mature understanding of themselves as boys or girls on the pathway to becoming men or women. Medical professionals certainly should not make radical interventions into the bodies of young people on the basis of a misguided ideology of identity.
We Are Not “In” Our Bodies, We Are Our Bodies
No one is born in the wrong body, because no one is born “in” a body. Rather, we are our bodies. There is nothing that could be “in” the wrong body, for the soul is the substantial form of the body—not some sort of separate substance.
Human beings are not non-bodily persons who inhabit and use non-personal bodies. We are not ghosts in machines. Our bodies are essential aspects of ourselves as the kind of entity we are—a certain type of animal with a rational nature, a human being. We—you, I, and every other human being—are personal bodily organisms. And the sex of an organism is determined by how that organism is organized with respect to sexual reproduction. As there are two complementary ways of being sexually organized, so there are two sexes: male and female.
The sexual binary is a biological reality. There is no scientific—indeed, no non-ideological—ground for denying it. That some people experience disorders of sexual development, sometimes referred to as intersex conditions, does not negate this reality. Disorders of sexual development do not constitute a third sex or a spectrum of sex. There is no third gamete, no third gonad, no third genital, no third reproductive system. Nor is there a “spectrum” between the two reproductive systems, despite the reality that these two systems can and sometimes do develop in certain disordered ways. (For more on this, see Chapter 4 of When Harry Became Sally.) It is a red herring to point to physical developmental disorders to justify an ideological view of gender as something fluid, non-binary, and utterly detached from our embodiment as male or female.
“Gender Affirmation” Is Based on Ideology and Sex Stereotypes
Of course, people can express their sexual identity as male or female in a variety of ways. They can conform to prevailing cultural norms or stereotypes, or they can deviate from them. They may feel comfortable with prevailing cultural expectations for persons of their sex, or they may feel uncomfortable. They can decide to act in a “gender non-conforming” way, or they can opt to be conventional. None of this, however, changes whether someone is male or female.
And yet, a growing and influential segment of our medical and educational establishments insist that someone’s sex is merely “assigned” at birth, and therefore might have been misassigned and can now be reassigned through “gender affirming” therapies. Here we see ideology calling the tune and scientific fact being shunted aside. According to this ideology, the appropriate determinant of sex is “gender identity”—one’s putative “internal sense of gender” (what exactly that is, no one knows, but we are told that gender on this understanding is fluid and exists along a spectrum). When someone’s gender identity is at odds with his or her body, medical interventions are said to be appropriate and even desirable to align the body with the identity. The claim, made insistently and even indignantly, is that someone who identifies as a woman is a woman (even if “she”—the pronoun is insisted upon—is biologically male), and so medical technology should be used to provide that person with a “female” body.
This has obvious philosophical problems. If someone who identifies as a woman is a woman, then whatever sort of body that person has already is a woman’s body. A woman’s body, on this account, is just whatever body someone who “identifies” as a woman has. This, after all, is how you get headlines about a “woman’s penis,” or a “pregnant man.” So what is it that the person is aligning the body to?
Why should someone who identifies as a woman abide by “stereotypical” notions of what a woman’s body ought to look like? Why should that person take hormones and undergo surgery to conform to those stereotypes? We’ve gone from breaking down cultural sex stereotypes to creating an industry in plastic surgery to refashion bodies according to them. And if gender is fluid and exists along a spectrum, what sorts of bodies should “gender non-binary” or “gender-ambidextrous” people be given? What sort of hormones and surgery should doctors be providing them? One doctor offers “Penile Preservation Vaginoplasty” where a “neovagina” is created while preserving the penis and testicles.
Rather than recognize the incoherence of their worldview, however, those on the cutting edge of “gender theory” take up this last question and reply: whatever body parts, modifications, and hormones that person desires. As a 2019 Journal of Adolescent Health article put it:
With approximately one-third of TGD [transgender and gender diverse] adults and 40 percent of TGD youth identifying as nonbinary, care guidelines that reinforce binary systems of gender identity may limit access to clinical services and restrict the ability of nonbinary people to navigate medical systems. Framing gender as solely binary defines therapeutic options and outcomes only in reference to two gender experiences, which impacts access.
Moving beyond the binary is the next horizon of medical intervention. It also requires moving beyond medical diagnosis. Indeed, the most recent proposals for “gender care” assert that it need not be based on any diagnosis of gender dysphoria at all, and should merely operate based on an individual’s choice—provided the individual give “informed consent” for that choice. According to one recent state report,
Healthcare for TNG [transgender, nonbinary, and gender expansive/nonconforming] youth must be patient-centered and as low-barrier as possible. Informed Consent Models of transition-related healthcare access allow TNG patients to access the essential medical care that they need [sic: desire] without needing to get approval from a therapist or other mental health provider.
So a minor’s say-so is all it should take to radically transform their body—even to the point of causing permanent sterility.
Affirming Falsehoods, Mutilating Bodies
The philosophical problems highlight why this treatment protocol is misguided—indeed, why it violates sound norms of medical ethics. The purpose of medicine is to bring about human health and wholeness, human flourishing in the physical and psychological domains. Here health is understood not as the satisfaction of desires but as the well-functioning of the mind and body, where our various bodily systems achieve their ends—the circulatory system to circulate blood, the digestive system to digest nutrients, the respiratory system to absorb oxygen, etc.—and where our thoughts and feelings achieve their ends of bringing us into contact with reality. Thus, any medical intervention intended to affirm someone’s false beliefs is inherently misguided. Affirming a falsehood via medical technology gets it wrong, right from the start.