I've spent a fair bit of time since I ran across this paper pulling apart its web of tangled reasoning. (and tangled it is) My first inclination is to go through it point by point and describe why each paragraph is leaping to incorrect conclusions or is so filled with assumptions that the authors clearly have failed to adequately research the subject they are writing on. However, that would produce a huge, tedious rebuttal that doesn't really address the underlying problems with this paper.
In my study of this paper, I have come to recognize a series of serious flaws in the assumptions and evidence that the authors have used. These include basing their description of what Transsexualism is on some deeply flawed theoretical models; drawing on sources that are, at best, marginal voices in the research and treatment community and ignoring data and sources that clearly arrive at different conclusions than the authors of the paper set out to find.
In short, the authors set out to confirm the conclusions they already had in mind, and paid little heed to the breadth and depth of the research field.
The first thing that the authors set out to do is invalidate the notion of transsexualism. They do this through several basic tactics. First, they use the emotionally loaded language of "mutilation" to describe Gender Reassignment Surgery. Any reasonable assessment of the ethical implications of a given procedure would be expected to stay away from such language in the early stages of the paper as it clearly prejudices the interpretation of subsequent data.
The paper proceeds to describe transsexualism using Blanchard's notion of Autogynephilia. Fortunately for transsexuals in the world today, Blanchard's model isn't exactly the dominant theoretical model describing transsexuals. In fact, the view that gender identity occurs in a spectrum has become much more prevalent. The problem with the Autogynephilia model is that it uses two fairly absolute categorizations to describe transsexuals - both firmly rooted in the language of sexual identity. Whether we are talking about the "Kinsey Scale" (which was emulated by Harry Benjamin for transsexuals), such attempts to define bounded categories tend to break down when applied to the breadth and depth of human diversity. As a thought experiment, try defining what it means to be 'a man' or 'a woman' in today's society - it's trickier than you might imagine. Then consider how difficult it is to categorize people in general.
The narrative discussion about transsexuals in general focuses intensely on people's sex lives, while ignoring the far more crucial discussions around the individual's adaptation and integration with society. While we are certainly all sexual beings in some capacity, it seems to me more than a little problematic to attempt to describe people based on their sexual behaviours. Worse, the reference material cited to derive this narrative is often based on such small numbers as to be better viewed as anecdotal evidence rather than population evidence. Sadly, the authors hold up numerous anecdotes about poor adaptation and misconceptions as being "the general case", a logical inference that simply does not stand up to any reasonable analysis.
Sadly, they even go as far as to reference a television show called Sex Change Hospital, as if such a program is going to be any kind of meaningful guide to the breadth and depth of experience that is humanity. Even worse, their criticism is that the people who have surgery aren't always "perfectly passable". Transsexuals, like the rest of the population come in all sorts of shapes and sizes - not everybody is model material, how dare they apply such a standard to transsexuals? Such programs tend to emphasize the physical change that surgery brings, but do not (and cannot) explore the complex and often bewildering path that is transition - that goes on with the patient and their therapist over a period of years.
The paper implies that there are always underlying psychological problems associated with Gender Identity Disorder (GID).
Some therapists too readily accept a patient’s “I feel trapped in the wrong body” explanation and do not probe—let alone help the patient to resolve—the patient’s underlying narcissism, anger, and inability to embrace the reality of their sexual identity.
To make such a claim is indeed spurious. The WPATH Standards of Care are very clear about the handling of comorbid conditions.
3. Therapy should focus on ameliorating any comorbid problems in the child’s life,
Ideally, the clinician's work is with the whole of the person's complexity. The goals of therapy are to help the person to live more comfortably within a gender identity and to deal effectively with non-gender issues.
Assuming that a therapist is knowledgeable and working within the WPATH SOC guidelines, one might reasonably suspect that recommendations for steps such as surgery aren't likely to be made until other related issues are dealt with adequately.
Inevitably, as one might expect, the writers turn to NARTH for more "experts" to reinforce their overt hostility to transsexuality and its treatment. They quote a paper published on NARTH's website by a Dr. Breiner - a particularly offensive piece of work that I have already analyzed here.
Following down the NARTH path further, we find the usual attempt to establish childhood sexual abuse as a causal or root factor in transsexualism. We've seen this before with homosexuality - it wasn't a terribly successful strategy before, and I know of no legitimate research that establishes any kind of reasonable causal relationship beyond the usual assertions that large numbers of
Similarly, the attempt to link transsexuality with masochism is not only a very feeble argument, it's at best spurious to make such an association. While there are no doubt some transsexuals who are interested in S&M play, drawing the conclusion that their masochistic fantasies led them to transition is dubious at best.
When the authors finally do start addressing the ethical issues involved in providing treatment to transsexuals, they do so from this framework of questionable theoretical models, really awful logic and blatant misinformation. Needless to say, their conclusions are similarly flawed.
I'm going to restate some of their conclusions in my own words, in part because the objections the authors raise are often done in a manner that is elliptical relative to what they conclude.
GRS is unethical because it doesn't "really" change someone's sex. (That is to say a MTF transsexual will not be able to bear children after surgery)
I don't think anybody denies the limitations of GRS as it stands today. To say that it is therefore "mutilation" is to suggest that any surgery that reshapes the body at all is mutilation as well.
The accusation that because the person is not able to directly procreate after surgery ignores the fact that for many transsexuals, the dysphoria they experience is so severe that it is unlikely that they would procreate in the first place. Further, it reduces human sexual and romantic partnerships to the production of babies - a position that treats the people involved as mere objects, rather than as human beings.
Transsexuals are really just lying about themselves
This is possibly one of the most offensive accusations that you can level at a transsexual. The journey through one's inner self that is part and parcel of a thoughtful, reasoned transition takes one well beyond the idea that they could be "lying" to themselves.
The archetype of the 'transsexual as deceiver' is rooted in the same rubric that leads the authors to assume that the deeply flawed model of Autogynephilia actually meaningfully describes the overall population of transsexuals. One of the most glaring problems with Bailey's "The Man Who Would Be Queen" book is the fact that most of his subjects were found in drag bars. That's like going into an outlaw biker bar to interview motorcyclists and concluding that all motorcycle riders belong to criminal gangs.
Transsexuals are demanding that others lie on their behalf and they have no right to do so
Those who believe that it is impossible to change a person’s sex do not want to be insensitive to others, but neither should they be forced to lie by calling a man a woman or by calling a woman a man.
If someone is clearly presenting as a woman, treat them as a woman - it's not difficult. To call someone who is obviously MTF trans "sir" or "he" when she is obviously living as a woman is just as wrong as the schoolyard bully calling his target a "sissy".
The religious objection that it is impossible to "change one's sex" is a personal belief, and should be kept personal.
By providing GRS, the caregivers are not providing a medically justified procedure, and as such they are collaborating with the patient's mental disease
This is a restatement of Paul McHugh's position, which I have already addressed on this blog.
I will however, reinforce my statements about McHugh's position with the following from the WPATH Standards of Care (v6):
Sex Reassignment is Effective and Medically Indicated in Severe GID. In persons diagnosed with transsexualism or profound GID, sex reassignment surgery, along with hormone therapy and real-life experience, is a treatment that has proven to be effective. Such a therapeutic regimen, when prescribed or recommended by qualified practitioners, is medically indicated and medically necessary. Sex reassignment is not "experimental," "investigational," "elective,"cosmetic," or optional in any meaningful sense. It constitutes very effective and appropriate treatment for transsexualism or profound GID.
The ethical objections that are raised in this paper are also addressed quite effectively in the WPATH Standards of Care as follows:
How to Deal with Ethical Questions Concerning Sex Reassignment Surgery. Many persons, including some medical professionals, object on ethical grounds to surgery for GID. In ordinary surgical practice, pathological tissues are removed in order to restore disturbed functions, or alterations are made to body features to improve the patient’s self image. Among those who object to sex reassignment surgery, these conditions are not thought to present when surgery is performed for persons with gender identity disorders. It is important that professionals dealing with patients with gender identity disorders feel comfortable about altering anatomically normal structures. In order to understand how surgery can alleviate the psychological discomfort of patients diagnosed with gender identity disorders, professionals need to listen to these patients discuss their life histories and dilemmas. The resistance against performing surgery on the ethical basis of "above all do no harm" should be respected, discussed, and met with the opportunity to learn from patients themselves about the psychological distress of having profound gender identity disorder.
It is unethical to deny availability or eligibility for sex reassignment surgeries or hormone therapy solely on the basis of blood seropositivity for blood-borne infections such as HIV, or hepatitis B or C, etc.
It is a sad statement that the paper's authors could not even have been bothered to examine the WPATH Standards of Care, which addresses their concerns most directly.