Fact-checking transgender treatment myths, Part 2 – the David Reimer fallacy

In my last post, while discussing an inaccurate claim about transgender treatment recently made by Lenny Esposito on the Come Reason blog, I promised to come back to his past post Today’s Snake Oil Includes A Scalpel: The Damaging Treatment of Transgenderism for some much-needed fact-checking. In that post, Esposito claims that gender reassignment therapy is ‘a dangerous falsehood that many times proves deadly to the patients that should have been helped’, and goes on to cite various pieces of evidence to make a superficially convincing case for this claim. However, this is extremely misleading; Esposito’s post not only contains several significant errors and fallacies, it also ignores all the research that actually shows gender reassignment therapy to be beneficial overall for nearly all the people who opt for it. Some proper fact-checking is clearly sorely needed here and, with apologies for the delay in getting back to it, here we go.

There’s quite a bit in his post to discuss, so I plan to break it down into several short posts dealing with each point separately. First up, his discussion of David Reimer’s story.

[I]n 1967 he [Dr John Money] sought to change a two-year-old boy whose genitals had been damaged by a botched circumcision into a girl, reassuring the parents that the child would grow up never knowing the difference. But, as the Los Angeles Times reported, “the gender conversion was far from successful. Money’s experiment was a disaster for Reimer that created psychological scars he ultimately could not overcome.” David Reimer committed suicide at the age of 38.

While it’s not clear to what extent Reimer’s suicide was a response to his history of gender surgery and to what extent it was related to other significant problems in his very troubled life, there is no doubt at all that the gender conversion attempts performed on Reimer were, indeed, psychologically disastrous for him and contributed hugely to the distress in his life, and it is very likely that they played at minimum a significant role in his final tragic end. However, there’s a big problem with using that as an anti-gender reassignment argument: Reimer wasn’t transgender.

As Esposito himself states, Reimer was a boy who was reassigned to be raised as female after a badly botched circumcision operation destroyed his penis and John Money (who was hugely influenced by his wish to prove his particular theory about gender fluidity) convinced his family that raising him as a girl was the best way to salvage the matter. There were never any claims that Reimer was transgender. From a very early stage he clearly knew he was male and wanted to be male.

Now, of course, Reimer’s situation was unique and there are limits to how much of a conclusion we should draw from that one story; but it does strike me as notable that what we have in Reimer’s story is the story of a person being raised as female who knew all the time, on some level, that he should actually be male.  In other words, the experience that a transgender man [a person born into a female body but with an inner gender of male] grows up with. And he found it devastating and destroying. That really doesn’t strike me as a good argument for trying to convince someone who identifies with one gender that they’re actually the other.

Of course, I have little doubt that Esposito and his followers would argue that a transgender man’s experience of distress over growing up in the wrong body shouldn’t be treated in the same way because he isn’t ‘really’ a male (by which they would mean that he’s not chromosomally male, or possibly that he wasn’t born with a penis – I’m not quite sure what, specifically, their criterion is). But, whichever way you look at it, it strikes me as pretty illogical to take an example of someone who found it deeply distressing to grow up with an assigned gender that his own inner certainty was telling him to be wrong, who could not refuse his need to live as the gender that matched his inner knowledge of himself – and use that to bolster your claim that people who are deeply distressed at growing up with an assigned gender that their inner certainty tells them is wrong should not be allowed to live as the gender that matches their own inner knowledge of themselves.

Misinformation about gender reassignment therapy (part 1)

One topic that’s shown up on Christian blogs a lot lately (because it’s been in the mainstream news a lot lately) is that of transgender people and gender reassignment surgery. I’ve been reading a lot of dubious claims from these sorts of articles, which have been ringing my Fact Check Alert bell big-time. I don’t know a great deal about transgender issues, but, as a GP, I do know that medical opinion supports the availability of gender reassignment as a treatment for gender dysphoria. So, when non-medical groups with a heavy religious-based agenda in the matter try to claim that gender reassignment is bad for transgender people and we should be banning it in their interests, that rings alarm bells for me and I want to look at the evidence.

The latest such post that I saw was Bloodletting and the Modern Trans Movement, on the Come Reason blog by Lenny Esposito. Esposito argues that because doctors once used to believe in treatments such as bloodletting which are now discredited we should therefore assume that medical advice to provide gender reassignment therapy for transgender people is similarly incorrect. Or something like that, anyway. That of course is just a logical fallacy (by the way, if anyone knows the official name for that logical fallacy feel free to shout out – I don’t keep track of logical fallacy names myself) but the bit that hit my Fact Check Alert button in this post was this:

I’ve pointed out before how we have fifty years of data under our collective medical belts on gender reassignment surgery and we know that the suicide rate for those suffering from gender dysphoria is as high after sexual reassignment surgery (SRS) as it is prior to transitioning.

The link Esposito gave there is to a post he wrote last year titled Today’s Snake Oil Includes a Scalpel: The Damaging Treatment of Transgenderism, which rang my Fact Check Alert bell several more times and needs a post or several of its own to discuss, which I fully plan to do. In the interest of speed and clarity, I’m going to leave that to further posts rather than try to cover everything here. What it did not do, even with the cherry-picked and misleading evidence it cites, was support Esposito’s statement that suicide rates are as high after gender reassignment therapy as before. The post cited one study showing much higher suicide rates among transgender people post-reassignment than in the general population (though without pointing out that these high suicide rates were seen a few decades ago when anti-transgender bias was worse than it is now, and that they don’t show up in recent years), but nothing comparing rates of suicide in transgender people pre- and post-gender reassignment. So, whatever Esposito may have convinced himself he ‘knows’, he hasn’t in fact demonstrated anything of the kind.

So, I did a bit of digging around to see whether any such statistics do exist, and, as far as I can find out, they don’t. I did find this report on rates of suicide attempts in the transgender population overall, which is frightening; transgender people were almost ten times as likely as the general population to have attempted suicide at some point. Not surprisingly, this was strongly linked with experience of discrimination, bullying, rejection by family, or even outright violence, making it clear that, for those of us concerned about suicide risk among transgender people, one of the most important things we can do is to work to increase transgender acceptance. (Which, frankly, doesn’t seem to be a strong point among conservative Christians such as Esposito.) And this article cited studies also indicating markedly increased suicide rates in the transgender population (and, again, cited evidence that showed this to be linked to experiences of discrimination and family rejection).

However, I couldn’t find anything giving comparative figures for suicide rates, or suicide attempt rates, in pre-transition and post-transition transgender people. Which isn’t too surprising, by the way, since it’s the sort of question on which it’s hard to get data; but it does mean that it is not correct to state that we ‘know’ the suicide rates to be as high after gender reassignment as before. We know nothing of the kind.

So what information is available on how gender reassignment affects transgender people? Looking, I found this article reviewing the existing evidence as to how gender reassignment affects the mental health and quality of life of transgender people overall. According to the abstract, the authors of this summary found 28 studies that followed transgender people through gender reassignment therapy (surgical and/or hormonal) comparing their mental health after the procedure with before. What they found was that, psychologically, the majority of people were better off after gender reassigment.

Pooling across studies shows that after sex reassignment, 80% of individuals with GID reported significant improvement in gender dysphoria (95% CI = 68–89%; 8 studies; I2 = 82%); 78% reported significant improvement in psychological symptoms (95% CI = 56–94%; 7 studies; I2 = 86%); 80% reported significant improvement in quality of life (95% CI = 72–88%; 16 studies; I2 = 78%); and 72% reported significant improvement in sexual function (95% CI = 60–81%; 15 studies; I2 = 78%).

So, no matter how hard conservative religious groups or other anti-transgender groups try to spin evidence to make it look as though it supports their cause, the evidence is in fact that the best thing to do to help transgender people is a) to eliminate prejudice and discrimination against them, and b) to make gender reassignment available for those who, after counselling, want it.

The Lighthouse Keeper’s Lunch

The Lighthouse Keeper’s Lunch, by Ronda Armitage, is a favourite of my eight-year-old daughter’s. This is partly because it’s a fun story, and partly because we enjoy going through pointing out all the problems with it.

My daughter is a huge fan of the CinemaSins YouTube channel. (Yes, this is probably a terrible idea and bad mothering on my part, but she’s only interested in the reviews of children’s films, so hopefully she isn’t going to end up watching extracts from some weird slasher film while my back’s turned.) Last night, while she was reading this book for the umpteenth time, she declared ‘We really need to make a list of all the things wrong with this book like the Sin Counter does!’

And so here I am. (And, Ronda Armitage, if you’re reading this – my daughter absolutely loves your book. Plot bizarreness and all.)

Basic plot (with spoilers)

Simple enough. Mr Grinling works in a lighthouse. Every day, his wife makes a detailed and delicious packed lunch for him, and sends it to him down a cable transport system (they live in a cottage on the nearby cliff). Some seagulls get wise to this and start eating the lunch on the way down, leaving poor Mr Grimling lunchless. Mr and Mrs Grinling try a couple of different things to discourage the seagulls, eventually winning the battle when Mrs Grinling comes up with the idea of putting mustard sandwiches in his lunch. The seagulls don’t like the mustard sandwiches, and after a couple of days of this head off to seek their lunch elsewhere. Success! Well, except for the unfortunate fisherman who’s having his lunch eaten by seagulls at the end. But success for Mr Grinling, who gets his lunch.

Problems with the plot

(As opposed to problems with the gender role portrayal, which are pretty obvious.)

  1. Why on earth does Mrs Grinling send the lunch down a cable every day? Surely it would be far simpler to make it the day before so that Mr Grinling can take it over in his boat each day when he commutes? What would happen if the cable jammed and left his lunch dangling fifty feet in the air over the sea? What if the basket tipped off in a storm? (It definitely doesn’t look too secure in the pictures.)
  2. How do the seagulls have time to finish the lunch in the time it takes to slide down a cable? Sure, they could probably peck at it somewhat, but apparently they’re supposed to have completely finished it in the time it takes to get down the line (and this is not a small lunch).
  3. Mrs Grinling’s first attempt at foiling the seagulls is to tie the napkin to the basket – cue picture of Mrs Grinling standing triumphantly next to a ribbon-bound basket. In which she appears to have added one ribbon totally for decoration, as it runs horizontally round the basket, under the other ribbons, contributing nothing whatsoever to the ribbon-induced security of the basket. What was the point of that?
  4. But what’s far worse is her next plan – with Mr Grinling’s full co-operation, she decides to send their cat down the cable as well in order to scare away the seagulls. Yup. We have a picture of a terrified cat being placed in a basket despite his struggles, and then one of him cowering in the basket in terrified misery as he travels down this insecure cable arrangement, at risk of toppling fifty feet into the sea below and getting dashed against the cliffs. The Grinlings are totally OK with doing this. Someone report this couple to the RSPCA.
  5. Mrs Grinling finally comes up with the mustard sandwich plan, and we have a full-page picture of the seagulls spitting the sandwiches out with cries of revulsion. And – kudos to my daughter for picking up this particular point – the falling sandwiches show human-shaped bite marks, rather than beak-shaped bite marks. How exactly did this happen? Did the seagulls’ beaks somehow magically metamorphosize into human mouths for just long enough to take those fateful bites, then change back again?

 

So… what’s the moral? Maybe it’s that you should prepare for work the night before, a la Flylady; maybe it’s that being cruel to animals brings you no benefit, but, hell, you’ll also apparently suffer no consequences from it so why not give it a try. (Nope. Let’s not go with that one.) On the whole, I think it’s that it’s probably not a good idea to overanalyse children’s books.

What I’ve been reading – the ‘My Friend Flicka’ series

In a complete and utter change of pace from my last ‘What I’m reading’ post, I’ve recently been revisiting Mary O’Hara’s classic series (My Friend Flicka, Thunderhead, and Green Grass of Wyoming) about life on a Wyoming ranch. I got onto this because I happened to find My Friend Flicka in a charity shop browse; I actually, as it happens, have had Thunderhead on my shelves for a while now having found a second-hand copy somewhere or other, probably in another charity shop browse, so I decided to go ahead and complete the set and ordered a used copy of Green Grass cheaply on Amazon and read the lot. I did read the books as a child, but in a skip-and-skim kind of way; parts of them interested childhood-me a lot, parts not at all. This re-read, therefore, was the first time I’d actually read them properly all the way through, and was an interesting combination of rediscovering sections that came back to me vividly as I read them, and being struck by aspects of them that had zoomed over my head the first time.

One thing I realised for the first time was just how long ago these were written; as a child, I don’t think I’d really taken in that they actually date back to the 1940s. (I’m not sure whether that’s a tribute to the timelessly good writing or an indictment of my powers of observation.) Reading it as an adult (and a doctor), I was struck by the fact that the reason Ken and Flicka both come so close to dying in the first book was because this was the pre-antibiotic era and there simply wasn’t much that could be done for severe infections. And by the fact that the McLaughlins don’t even get a phone until the third book and that this is so taken for granted it barely rates a mention.

More insidiously, there’s also the way the female characters are presented. When I read the first book as a child, the character I identified with was the eponymous Flicka, for the simple reason that the only human female character who gets more than a very brief walk-on part in the whole of the first two books is Ken’s mother Nell. Who spends half her time planning meals for the menfolk and half of it fretting over the way her husband is taking his frustrations and fears over their money worries out on her. Rereading the books, I found new appreciation for Nell’s character; she is beautifully portrayed, a complex, intelligent, sensitive woman caught in the hell of an insoluble situation. But, other than the occasional scene where her sons go to her for advice or homilies, she doesn’t really do anything that my childhood self could either identify with or aspire to.

In the third book we get two more female characters – Carey, beautiful and sweet but passive and immature (at one point in the book, her response to Ken’s attempt to discuss her plans for her future is to go into rhapsodies over how adorable the eight children she wants are going to be and won’t Ken join her in her game of planning names for them?), and her monstrously manipulative grandmother, whose determination to keep Carey under her thumb is largely responsible for Carey’s failure to grow up. O’Hara does an excellent job of portraying a deeply manipulative relationship and the difficulties of breaking free after years of being groomed to find this manipulation normal, and I can recommend this as a great piece of writing; but, again, it’s not something in which, as a child, I could find a role model or a character I really felt good about identifying with.

Even the way O’Hara writes about the horses drifts off into a male-dominated picture. This, of course, is partly because horses by their nature live in a male-dominated world – as unintentionally exemplified by this snippet from Green Grass of Wyoming, in which Ken tries to explain to the naive Carey why her filly Jewel has been stolen by his stallion Thunderhead:

‘…It’s kind of like falling in love. He knew she was a winner and he just kicked the crate to pieces until she was free and ran away with her – kind of eloping.’

‘But what if she didn’t want to go?’

Ken grinned. ‘Well, he’d make her. That’s what a stallion does. But he’ll take good care of her – Oh, the very best care! You don’t need to worry about her coming to any harm!’

Carey’s tears were drying and she looked at Ken, intrigued by this strange tale of wild-animal romance.

Ah, yes, that well-known sign of a great romance – one of the pair is quite happy to force the other one against zir wishes without, in fact, caring in the slightest what zie wants. Exactly the example we want to be giving to young people.

That, of course, is simply a case of horses not really being the best role models for human relationships; but it also occurred to me, as I read, that O’Hara even let her female equine characters fade into the background once a stallion was in the picture. In the first book, Flicka’s supposed to be Ken’s one chosen horse and true love forever (which ends up being quite a raw deal for Flicka, as the attempts to capture her for Ken unintentionally lead to her receiving a near-fatal injury which leaves her forever robbed of the incredible speed that caught Ken’s attention in the first place). But the second and third books focus on her son, Thunderhead. Flicka does go on to have a daughter, Touch And Go, who in fact becomes the one to save the ranch at the end of the second book by winning a crucial race and thus paying off the family’s crippling debts, but this scene is mentioned almost in passing as the book gets back to the far more important issue of Thunderhead’s fate. By the third book, Flicka barely figures and Touch And Go, gets one single brief passing mention; even though the racehorse owner who bought her figures largely in the story, there isn’t so much as a passing question or mention as to how Touch and Go is doing, and Thunderhead is talked about as though he’s the only racehorse in the bunch.

There were, conversely, many aspects of the book I appreciated far more on a reread; Ken’s development and growth through the novel and the beautiful and vivid depictions of Wyoming ranch life. I remembered why I did like these books as a child, but I also had more conscious awareness of what it was about them that left me not feeling as comfortable.

Who here has read the books? What did you think of them and what do you think of them on looking back?

How true…

This cartoon from the Doc Rat site appeared in a recent British Journal of General Practice. Maybe it’s a bit too much of an in-joke, but it amused me so much that I cut it out and stuck it on my study wall.

Reminds me of the old joke about dermatology that we all heard at medical school: ‘Describe it in Latin and give them steroid cream’.

Friday the 13th and sex work advocacy

A few years back, I used to read a blog by a retired escort worker who now blogs, under the name of Maggie McNeill, for the rights of sex workers. I drifted away due to time constraints, and, since then, have gradually realised that I actually disagree with her on some very fundamental issues around feminism and consent, so if you check out her blog (The Honest Courtesan) do be aware that there is a lot of stuff on those topics that I would not endorse and that I think most people here wouldn’t either. (Also, of course, there’s a lot of very NSFW stuff on there.) However, I do agree with her on the main point her blog seeks to make; sex work should be decriminalised. What’s more, laws intended to provide legal protection for sex workers need to be worked out with the guidance of actual sex workers, using a model that puts their agency first rather than framing them as helpless victims who need protection.

Anyway, I’m posting about this now due to a rather nice idea that Maggie had- namely, to make every Friday 13th a day for sex workers and non-sex workers alike to speak out in favour of decriminalisation of sex work. As Maggie wrote:

Let’s start getting the word out that whores are no different from other women, and that “a woman’s right to choose what to do with her own body” is more than just a euphemism for abortion.

I quite agree, and so, ever since running across this custom of hers (a year or two after she’d instituted it) I’ve tried to stick to it, every Friday 13th. (Successfully, in fact, if we gloss over the one time I missed the precise date and sent a text to a friend about it on Saturday 14th instead.) You can read two posts about this on my old blog (on other Friday 13ths between then and now, I’ve posted or commented in other places):

  • Their Bodies, Their Choice is a general explanation of my view on the matter (sorry about the paragraph breaks, by the way – I moved that blog from Typepad to WordPress and some of the formatting on the archives got messed up in the process)
  • Anti-Prostitution Laws: The Trouble With The Swedish Model is a post in which I discuss the problems with the commonly-advocated idea of making prostitution itself legal but making it illegal to be a client of a prostitute.

This, of course, will be the first Friday the 13th post on Geeky Humanist. Yay! A chance to spread the word to a wider audience.

As I’m in the UK and I know the readership here is heavily, though not exclusively, from the US, I think it’s worth explaining a bit about the different laws. Unless I’ve missed any recent updates, the law in nearly all of the US is that prostitution itself is illegal; a draconian waste-of-resources law that benefits nobody (other than, I suppose, politicians looking to score points with the Religious Right) and is simply not morally defensible under anything other than a religious or quasi-religious form of sexual morality. Anyone here really want the police spending their time and resources on prosecuting consensual sex (which most prostitution is) when they could be putting that effort into better prosecuting crimes like rape or domestic violence?

In the UK, we’re at least somewhat more enlightened, in that it’s not against the law either to sell or to buy sex. (The latter is unfortunately in danger of changing – see below – but I think at least we’re safe on the former; I’ve never heard of anyone here wanting to make prostitution itself illegal.) But we do, alas, still have several laws on the books that make life far more difficult than it needs to be for sex workers.

Looking for up-to-date information on British law for this post, I found this useful leaflet from the English Collective of Prostitutes’ site informing sex workers of their rights, which lists the laws in straightforward layperson’s language. Some of this I already knew; I was aware, for example, that it is illegal in the UK to earn money from organising prostitution, and that, while this law was probably set up with the good intention of wanting to prosecute genuinely abusive pimps who are forcing women into prostitution in order to make money off them, it has backfired badly by preventing many, many sex workers from seeking the extra protection that could come from working together/organising brothels with proper security services.

I didn’t, however, know about the law on prostitute’s cautions, and this one really shocked me. Apparently, it is still quite legal in the UK for two police officers to record a ‘caution’ about anyone whom they believe to be loitering publicly for purposes of soliciting, without having to present any evidence – and the person cautioned has no right of appeal against it. Good grief – I’m sure that law never gets abused, then. Two such cautions in a period of three months can lead to a conviction for soliciting, which then shows up on any further enhanced criminal records check done during the person’s lifetime. This article describes the problems this archaic law can cause.

On top of this, there’s a vocal lobby in favour of outlawing the buying of sex (the legal system known as the Swedish or Nordic Model, which I discussed in the second of my two linked posts above). Despite the fact that the English Collective of Prostitutes vehemently oppose this idea, the Home Affairs Committee are currently looking into the possibility of recommending this change in law to the government. That one is still a ‘watch this space’, and the latest development seems to be positive; three days ago, the Committee heard evidence from retired sex workers Brooke Magnanti and Paris Lees, who are also both firmly opposed to bringing in such a law, and they seem to have been willing to at least take that viewpoint on board and consider the possibility of recommending more constructive changes such as abolishing the law against brothel working. The transcript (which also has a link to the video, if that’s what you prefer) can be found here and makes excellent reading.

So we can hope that that one will be a non-starter. But it’s nevertheless clear that, when it comes to protecting sex workers or to taking them seriously as people who should have input into the laws that are supposed to protect them, UK law and UK society still have a long way to go. I guess I’ll be blogging about this on a good many Friday the 13ths to come.

Pregnancy test before X-ray?

Browsing the Internet, I came across Jessica Caldwell’s essay Fractured: A First Date, in which she tells her story of breaking her arm in a drunken flirtatious arm-wrestling session. What struck me about it was that, when the doctor saw her in the emergency room, he told her that he would need to do a pregnancy test to confirm she wasn’t pregnant before he could X-ray her arm.

Wait, what? I get that, if a woman is pregnant, it’s worth thinking about whether a particular X-ray/CT can be postponed a few months until she no longer has a passenger to share in the radiation dose; doses from X-rays are trivial, but can add up over a lifetime and it makes sense to limit them. But Caldwell had a broken arm. Her X-ray was essential and couldn’t wait.

I’m wondering – what on earth would that doctor have done if Caldwell’s pregnancy test had been positive? Left her with a second elbow in her arm for the next nine months? Put a cast on it sans X-ray and kept fingers crossed that it didn’t heal too crooked? You know, I formulated those questions as flippant ones… thinking about some of the scary things I’ve heard about the dominance of pro-life thinking in the USA, I’m actually not too sure. If Caldwell had been pregnant, would she actually have found her doctors putting that embryo’s priorities before hers and denying her the X-ray she needed for her medical care?

I now have a header!

Took me long enough, I know. Well, it’s nothing to write home about – just something I threw together on Canva – but I like it and, at any rate, it’s a big improvement on not having any header.

If anyone has any particular suggestions about how it could be improved, fire ahead.