his shouldn’t be controversial. Sex is understood this way across sexually reproducing species. No one finds it particularly difficult—let alone controversial—to identify male and female members of the bovine species or the canine species. Farmers and breeders rely on this easy distinction for their livelihoods. It’s only recently, and only with respect to the human species, that the very concept of sex has become controversial.
And yet, in an expert declaration to a federal district court in North Carolina concerning H.B. 2 (a state law governing access to sex-specific restrooms), Dr. Deanna Adkins stated, “From a medical perspective, the appropriate determinant of sex is gender identity.” Adkins is a professor at Duke University School of Medicine and the director of the Duke Center for Child and Adolescent Gender Care (which opened in 2015).
Adkins argues that gender identity is not only the preferred basis for determining sex, but “the only medically supported determinant of sex.” Every other method is bad science, she claims: “It is counter to medical science to use chromosomes, hormones, internal reproductive organs, external genitalia, or secondary sex characteristics to override gender identity for purposes of classifying someone as male or female.”
In her sworn declaration to the federal court, Adkins called the standard account of sex—an organism’s sexual organization—“an extremely outdated view of biological sex.”
Dr. Lawrence Mayer responded in his rebuttal declaration: “This statement is stunning. I have searched dozens of references in biology, medicine and genetics—even Wiki!—and can find no alternative scientific definition. In fact, the only references to a more fluid definition of biological sex are in the social policy literature.”
Just so. Mayer is a scholar in residence in the Department of Psychiatry at the Johns Hopkins University School of Medicine and a professor of statistics and biostatistics at Arizona State University.
Modern science shows that our sexual organization begins with our DNA and development in the womb, and that sex differences manifest themselves in many bodily systems and organs, all the way down to the molecular level. In other words, our physical organization for one of two functions in reproduction shapes us organically, from the beginning of life, at every level of our being.
Cosmetic surgery and cross-sex hormones can’t change us into the opposite sex. They can affect appearances. They can stunt or damage some outward expressions of our reproductive organization. But they can’t transform it. They can’t turn us from one sex into the other.
“Scientifically speaking, transgender men are not biological men and transgender women are not biological women. The claims to the contrary are not supported by a scintilla of scientific evidence,” explains Mayer.
Or, as Princeton philosopher Robert P. George put it, “Changing sexes is a metaphysical impossibility because it is a biological impossibility.”
The Purpose of Medicine, Emotions, and the Mind
Behind the debates over therapies for people with gender dysphoria are two related questions: How do we define mental health and human flourishing? And what is the purpose of medicine, particularly psychiatry?
Those general questions encompass more specific ones: If a man has an internal sense that he is a woman, is that just a variety of normal human functioning, or is it a psychopathology? Should we be concerned about the disconnection between feeling and reality, or only about the emotional distress or functional difficulties it may cause?
What is the best way to help people with gender dysphoria manage their symptoms: by accepting their insistence that they are the opposite sex and supporting a surgical transition, or by encouraging them to recognize that their feelings are out of line with reality and learn how to identify with their bodies?
All of these questions require philosophical analysis and worldview judgments about what “normal human functioning” looks like and what the purpose of medicine is.
Settling the debates over the proper response to gender dysphoria requires more than scientific and medical evidence. Medical science alone cannot tell us what the purpose of medicine is.
Science cannot answer questions about meaning or purpose in a moral sense. It can tell us about the function of this or that bodily system, but it can’t tell us what to do with that knowledge. It cannot tell us how human beings ought to act. Those are philosophical questions, as I explain in “
When Harry Became Sally.”
While medical science does not answer philosophical questions, every medical practitioner has a philosophical worldview, explicit or not. Some doctors may regard feelings and beliefs that are disconnected from reality as a part of normal human functioning and not a source of concern unless they cause distress. Other doctors will regard those feelings and beliefs as dysfunctional in themselves, even if the patient does not find them distressing, because they indicate a defect in mental processes.
But the assumptions made by this or that psychiatrist for purposes of diagnosis and treatment cannot settle the philosophical questions: Is it good or bad or neutral to harbor feelings and beliefs that are at odds with reality? Should we accept them as the last word, or try to understand their causes and correct them, or at least mitigate their effects?
While the current findings of medical science, as shown above, reveal poor psychosocial outcomes for people who have had sex reassignment therapies, that conclusion should not be where we stop. We must also look deeper for philosophical wisdom, starting with some basic truths about human well-being and healthy functioning.
We should begin by recognizing that sex reassignment is physically impossible. Our minds and senses function properly when they reveal reality to us and lead us to knowledge of truth. And we flourish as human beings when we embrace the truth and live in accordance with it. A person might find some emotional relief in embracing a falsehood, but doing so would not make him or her objectively better off. Living by a falsehood keeps us from flourishing fully, whether or not it also causes distress.
This philosophical view of human well-being is the foundation of a sound medical practice. Dr. Michelle Cretella, the president of the American College of Pediatricians—a group of doctors who formed their own professional guild in response to the politicization of the American Academy of Pediatrics—emphasizes that mental health care should be guided by norms grounded in reality, including the reality of the bodily self.
“The norm for human development is for one’s thoughts to align with physical reality, and for one’s gender identity to align with one’s biologic sex,” she says. For human beings to flourish, they need to feel comfortable in their own bodies, readily identify with their sex, and believe that they are who they actually are. For children especially, normal development and functioning require accepting their physical being and understanding their embodied selves as male or female.
Unfortunately, many professionals now view health care—including mental health care—primarily as a means of fulfilling patients’ desires, whatever those are. In the words of Leon Kass, a professor emeritus at the University of Chicago, today a doctor is often seen as nothing more than “a highly competent hired syringe”:
The implicit (and sometimes explicit) model of the doctor-patient relationship is one of contract: the physician—a highly competent hired syringe, as it were—sells his services on demand, restrained only by the law (though he is free to refuse his services if the patient is unwilling or unable to meet his fee). Here’s the deal: for the patient, autonomy and service; for the doctor, money, graced by the pleasure of giving the patient what he wants. If a patient wants to fix her nose or change his gender, determine the sex of unborn children, or take euphoriant drugs just for kicks, the physician can and will go to work—provided that the price is right and that the contract is explicit about what happens if the customer isn’t satisfied.
This modern vision of medicine and medical professionals gets it wrong, says Kass. Professionals ought to profess their devotion to the purposes and ideals they serve. Teachers should be devoted to learning, lawyers to justice, clergy to things divine, and physicians to “healing the sick, looking up to health and wholeness.” Healing is “the central core of medicine,” Kass writes—“to heal, to make whole, is the doctor’s primary business.”
To provide the best possible care, serving the patient’s medical interests requires an understanding of human wholeness and well-being. Mental health care must be guided by a sound concept of human flourishing. The minimal standard of care should begin with a standard of normality. Cretella explains how this standard applies to mental health:
One of the chief functions of the brain is to perceive physical reality. Thoughts that are in accordance with physical reality are normal. Thoughts that deviate from physical reality are abnormal—as well as potentially harmful to the individual or to others. This is true whether or not the individual who possesses the abnormal thoughts feels distress.
Our brains and senses are designed to bring us into contact with reality, connecting us with the outside world and with the reality of ourselves. Thoughts that disguise or distort reality are misguided—and can cause harm. In “
When Harry Became Sally,” I argue that we need to do a better job of helping people who face these struggles.
This piece originally appeared in The Daily Signal
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