Tuesday, April 04, 2017

Comparing Transsexualism With Body Integrity Identity Disorder

Today, right-wing opinion site "The Federalist" published an essay "Woman Demands Doctors Sever Her Spinal Cord To Align Body To Mind (Same as a Transsexual Man)" by Glenn T. Stanton.

The basic argument that Mr. Stanton is making is that gender reassignment surgery isn't necessary.  He does this through a rather roundabout argument that attempts to link Gender Dysphoria (GD) with Body Integrity Identity Disorder (BIID).

Phenomenologically speaking, GD and BIID carry some significant similarities.  Perhaps the most striking of these is that patients who experience these conditions frequently can trace it back to their early childhood memories (First, & Fisher, 2012).  Second, both describe significant dysphoria resulting from their condition, and may seek medical or psychological intervention to alleviate these symptoms.  Dysphoria is a shockingly rational experience, quite distinct from clinical anxiety or other experiences.

So, on the surface, it would seem that Mr. Stanton has a point worthy of consideration.  Let's dig a little deeper shall we?
Trans advocates resist this comparison, claiming these are very different things. How? Well, they say one is made up and the other is real. They say one is a severe psychosis and one is natural. Can you guess which evaluations apply to which condition? It is a convenient way to understand the two if you’re transgender, but are they really that different? Researchers who study these individuals report they rarely demonstrate any other type of psychosis beyond this condition.
Here's the first error in Mr. Stanton's argument.  He links to an article talking about Body Dysmorphia Disorder (BDD), which is not the same thing as BIID.  There is an important distinction between the two, and that is the presence of dysphoria which is distinct from anxiety.  An examination BDD in the DSM-5 is quite clear about the issues that separate the two.  BIID is still relatively new, and not well researched at this time (First, & Fisher, 2012; Song, 2013).

Mr. Stanton should have done his research more carefully, and recognized the distinction between BIID and BDD.  Additionally, had he taken the time to consult with clinical experts in the field, he would have learned quite quickly that conflating two distinct conditions would be unhelpful to his argument.
The similarities? A constant and deep feeling of incongruity between one’s body and actual sense of self, most reporting they’ve “always felt this way.” Both exist in the mind of the person. The individual is willing to go to great lengths, expense, complex processes, and severe pain to “align” body and mind. The differences are actually minimal.
I think it is important to acknowledge here that BIID and GD share phenomenological similarities, but I would be very cautious indeed about arguing that the differences are "minimal".  As noted in First and Fisher (2012), BIID is a relatively recent area of study, and there is a definite lack of research, or even treatment protocols for treating it.  In comparison, one can argue that GD has over a century of research associated with it, going back to the work of Magnus Hirschfeld (Please note: the term transvestite has a much narrower meaning today than it did when Hirschfeld coined it in 1910).

Stanton uses this trivialization to justify using a long term follow-up study of transsexual persons in Sweden (The Swedish Study) by Dhejne et al (2011) to assess the usefulness of surgery as part of the treatment for transsexuals.  The Swedish Study found that transsexuals experience significantly elevated rates of suicide, psychiatric care needs and other mental health issues (Dhejne et al, 2011).  According to Stanton, this is evidence that Gender Reassignment Surgery (GRS) is ineffective.
In contrast to the general population in Sweden, those who have undergone sex reassignment surgery in that extremely gender-variant country are:
  • Three times more likely to die prematurely from any cause.
  • Nineteen times more likely to die from suicide.
  • Three times more likely to die from cardiovascular disease.
  • Three times more likely to require psychiatric hospitalization.
  • Two times more likely to engage in substance misuse.
  • Two times more likely to commit violent crime.
Of all the health categories the researchers examined, only suffering “any accident” or committing “any crime” were less than two times greater than the general population. The scholars conclude, “Even though surgery and hormonal therapy alleviates gender dysphoria, it is apparently not sufficient to remedy the high rates of morbidity and mortality found among transsexual persons.” Cutting the body does not seem to heal the mind.
Unfortunately for Stanton, the first thing that The Swedish Study authors acknowledge is that GRS does alleviate symptoms associated with Gender Dysphoria (Dhejne et al, 2011).  What it does not address are the causes of the additional psychiatric morbidity that transsexual persons experience.   It is no particular secret that resolving GD symptoms does not magically make other issues go away.  Further, we must acknowledge that transgender people in general experience extremely high rates of rejection, discrimination and isolation that vastly exceed those of the general population (Testa et al, 2017).  To assume that this somehow invalidates the use of surgery to address symptoms associated with GD is simply wrong.

Like many other political writers, Mr. Stanton has fallen into the trap of failing to read the results of a study with due care.  As a result, he has grossly misinterpreted them and their meaning.
Patients are seldom well-served by ideology and beliefs crafted from political expediency. For their sakes, we must be honest about what we are dealing with here, and the similarities between these two conditions should be instructive.
Stanton concludes his argument by attempting to reduce nearly 70 years of research since Harry Benjamin started working with transsexuals to mere "political expediency".  His attempt to do so by connecting GD with BIID is an unfortunate, and ill-informed attempt to invalidate the treatment of transsexual persons by pointing out the very legitimate and complex issues that BIID presents from a treatment perspective.


In all fairness, BIID is in its infancy as a recognizable condition.  It will take time to develop a clear understanding of the condition itself, and the most effective approaches to treating it.  Just as it has taken decades to develop the current understandings related to Gender Dysphoria, it will take time to establish a reasonable, evidence-based approach to Gender Identity.  Right now, BIID does not exist as a discrete diagnosis in the DSM-5, but that likely is a reflection of the issues previously mentioned with respect to research in this domain.

The degree to which treatment of BIID will be informed by the experience of GD, or vice versa, remains to be seen.

(* Clarification:  Although we are talking primarily about BIID and GD in this essay, I want to be very clear that BIID, BDD and GD are all serious conditions that deserve to be treated with compassion, not erasure *)


Dhejne, C., Lichtenstein, P., Boman, M., Johansson, A. L. V., Långström, N., & Landén, M.,(2011). Long-term follow-up of transsexual persons undergoing sex reassignment surgery: Cohort study in sweden. PloS One, 6(2), e16885. doi:10.1371/journal.pone.0016885
First, M. B., & Fisher, C. E. (2012). Body integrity identity disorder: The persistent desire to acquire a physical disability. Psychopathology, 45(1), 3-14. doi:10.1159/000330503
Song, R. (2013). Body integrity identity disorder and the ethics of mutilation. Studies in Christian Ethics, 26(4), 487-503. doi:10.1177/0953946813492921
Testa, R. J., Michaels, M. S., Bliss, W., Rogers, M. L., Balsam, K. F., & Joiner, T. (2017). Suicidal ideation in transgender people: Gender minority stress and interpersonal theory factors. Journal of Abnormal Psychology, 126(1), 125-136. doi:10.1037/abn0000234

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