Why the gender debate should focus on the medicine.

By Anonymous MD

Editor's Note: This article is an updated version of a previously published piece by Anonymous MD that makes use of footnotes. Scroll to the bottom to see the references.

I am a physician, a husband, and a father. I am a religious man; my faith is at the very center of my life. I am fiscally conservative and believe in evidence-based, small-government solutions to problems. I subscribe to objectivist philosophy (as popularized by Ayn Rand). I find the main reason for the increased cost of care and the lack of access to it to be third-party interference, either from insurance companies or from the government. 

Given this background, it may be surprising to learn of my unusual medical history. I was identified as a female at birth and subsequently raised as a girl. As a junior in college, I completed a gender transition, going through male puberty and having gender confirmation surgery to allow me to live as the man I always was.

Gender dysphoria is the condition of having distress associated with a strong identification with the opposite gender as one’s assigned sex at birth. It is a complex disorder. I have a unique perspective on the issue, and it is my hope that by sharing it I might encourage others to think critically about this incredibly controversial and politicized topic. In my opinion, we should ignore the politics and focus instead on the science and the patient. So let’s start with some medical definitions.

“Intersex” disorders, or disorders/differences of sexual development, are conditions whereby individuals have genitals, chromosomes, hormones, or reproductive organs that don’t fit into the male/female sex binary. The existence of those with “intersex” disorders presents a challenge to those who say that the physical features you are born with and your chromosomes will determine your gender. There are a large number of disorders of sexual development that lead to differences in physical and hormonal presentations. However, people with these disorders may identify as either male or female, without regard to their chromosomes or physical features. This phenomenon leads to the logical conclusion that the brain is the most important sex organ in the body. 

Modern research demonstrates those with medically diagnosed gender dysphoria may have a physiologic explanation for their disorder. Using MRI, multiple researchers have found congruity in brain activity between those with gender dysphoria and those with neurotypical brains aligning with their identified gender. For example, persons assigned as female at birth but who identify as male now were found to have the same kind of brain activity as neurotypical males, instead of that of neurotypical females. Other studies mapping neurometabolic features found that those who identified as transgender tend to have their own unique neurological physiology, different from either neurotypical males or females. Some studies have found evidence that these differences in brain structure and function originate in the womb. (1-6) The science is new and rapidly developing, but there is enough of it to convince me that people with medically provable gender dysphoria are not simply “confused.” Rather, these are medical issues requiring medical solutions.

Relatedly, as a man of faith, it saddens me when individuals say that God would not make a “mistake” in creating a transgender person. This argument is quite silly. As a physician, I regularly see people born with ailments of all kinds. God doesn’t make “mistakes” with these people. Nor do people foist politically motivated attacks at them. In my experience, because of the highly contentious atmosphere surrounding gender dysphoria, religious individuals may be suspicious of people with gender differences. They worry that they have fallen victim to an ulterior political motive — that society or institutions have pushed an agenda at them that threatens their religious freedoms. In some cases, they may be right. Certainly, the political context provides some circumstantial evidence: There does seem to be remarkable bias against conservative and religious individuals in many institutions of science, and there is an effort to silence or “cancel” those who disagree with the cultural movement of gender fluidity or gender nonconformity. There is a powerful, political, and/or profit-driven effort within institutions of higher learning, some governmental agencies, and even private corporations to support socially driven changes surrounding gender identity.

For the sake of treating intersex and gender dysphoric conditions, this cultural movement is a catastrophic mistake by society; it is harming, and will continue to harm, people like me with gender differences through a culture of deferential treatment. When I started my gender transition, professors who had previously disliked me for my conservative views suddenly embraced me and improved my grades. Two of my physicians did not even ask if I had seen a psychiatrist but were eager to perform surgery and prescribe medication without the appropriate workup. For any other medical condition, this is highly unusual. Through my training and practice, I have never seen this happen in any other setting than the politically charged atmosphere surrounding gender dysphoria.

Deciding that everyone has the right to choose their gender, not treating those who need treatment, is like putting the cart before the horse. And “canceling” those who challenge this idea will ultimately create a new politically protected class of minorities. This is extremely harmful when practiced in an institutional setting like a doctor’s office.

The harm can be seen through several examples of activist medicine that deviate from common sense. For example, some might advocate for “real-life experience” trials in children who do not yet have gender constancy, a fixed idea about their own gender. This concept of gender constancy develops at around age 7-8 — after gender identity is recognized at age 2-3. (7) Logically, it seems like a big problem to allow a child to live “full time” as the other gender before they have the cognitive capability to understand that gender cannot change. Some advocate for life-altering surgeries and hormone replacement therapy in teens too young to fully comprehend the gravity of their decision. Research shows that most of the children diagnosed with gender dysphoria will identify as their “birth gender” after the age of puberty (with or without going through puberty itself). (8,9) This is a very inconvenient truth for some activists.

It is not often recognized that many with gender dysphoria have concomitant mental illnesses. (10,11) These disorders need to be treated first. An analogy would be an individual with decompensated liver cirrhosis and an umbilical hernia. We do not treat the hernia until we treat the cirrhosis because otherwise we put the patient at risk for significant complications, and endanger the hernia repair itself. First, we control the cirrhosis, and then we address the hernia. Doing this does not mean that we are saying the hernia is not a problem. And it does not mean that we are saying there is no hernia, either. A patient presenting with symptoms of gender dysphoria should be evaluated for other psychological issues, and treatment for those conditions should be carefully considered prior to proceeding with invasive treatment for gender dysphoria.

Current data suggests that children too young to pursue definitive treatment can likely be safely treated with what we call a “temporizing” measure – puberty blockers. You may have heard of “hormone replacement therapy,” but to be clear, that kind of therapy is not the same as “puberty blockers.” Hormone replacement therapy is giving the appropriate amounts of supplemental estrogen or testosterone to a person to induce puberty or maintain a masculine or feminine physique. “Puberty blockers” halt naturally occurring puberty for a time. Hormone replacement therapy results in permanent changes associated with puberty; puberty blockers do not result in these changes. 

Some politicized doctors have warned that side effects from puberty blockers are deleterious. In reality, the side effects are not any more egregious than other hormone therapies sometimes prescribed to children. When appropriately prescribed, they have the potential to help a child get through a very difficult time in their life. (12-14) There are risks associated with many treatments, and those risks should be thoroughly and openly discussed with the parents and the patient prior to initiating the treatment.

The severity of medically diagnosed gender dysphoria necessitates treatment. As someone who has experienced gender dysphoria myself, and as someone who has perused the literature on the topic to examine others’ experiences, there are few comparisons that can be made to describe the level of internal distress one experiences. Looking in the mirror daily provides, at best, an out-of-body experience. I could not look for long; it was like staring at something truly terrifying from the recesses of the most psychologically horrifying thriller film or nightmare. Except it was real. My reality was that I was trapped in an inescapable falsehood that everyone believed but me. 

With a focus on long-term goals, grit and determination, one can be materially successful while experiencing gender dysphoria. I graduated high school with honors, won awards, kept myself in good physical shape, participated in a number of extracurricular activities, and even had a few high-school side hustles for some extra cash. One can experience joy in everyday occurrences, have meaningful relationships, and live what looks like a full life. But one cannot live an authentic life, let alone one’s fullest life, with that ever-present horrific void even in dreams when you conceptualize yourself as the person you were always made to be. 

Cumulative stress mounts year after year as the most basic assertions about yourself, spoken from toddlerhood through adolescence, are met with rejection by every authority figure in your life. I questioned my own sanity. I questioned whether God existed, and if He did, why He would make a monster like me. I asked Him whether it was truly possible for someone like me to ever be loved, after being told by someone close to me that it was not. Many with this condition succumb to suicide. I am eternally grateful to God that I did not develop suicidal ideation, but puberty brought me close to it. The level of sheer horror and disgust I experienced at that time still occasionally gives me nightmares today. I credit God, heavy compartmentalization, and a focus on my future goals during that time for my survival. 

The dysphoria I experienced was a symptom of a medical condition rooted in my brain, whereby my brain’s physiology was fundamentally different from my chromosomes and hormones. The dysphoria itself was completely resolved once I was treated with the correct hormones and surgical intervention. This is not the right treatment for everyone. An individualized approach is fundamental to successful treatment. All medicine is about compromises, and providing an intervention that will result in the least amount of harm.

Focusing on the political fight for “rights” may seem noble, but making those with medically diagnosed gender dysphoria into political pawns, victims, or protected minorities is cruel and dangerous. They are patients, and they should be treated with objectivity. Additionally, we as a society must resist the politically motivated push to reject medically diagnosed gender dysphoria as a disorder. It is a deviation from normal physiology that causes a problem; this is the very definition of a disorder. There is evidence that shows when people with gender differences live in either a male or female role instead of a “gender fluid” role, they do better from a social, financial, and mental-health perspective. There is a reason why the InterACT Advocates for Intersex Youth, an advocacy and policy group for intersex individuals, recommends that parents of children with disorders of sexual development raise them in one gender or another instead of assigning them to a separate “intersex” gender. (15) Their rationale is that a separate “intersex” gender would separate them from society and would be unethical and cruel. This concept is not fundamentally different from raising a child with gender differences in a “gender fluid” role. While intersex and transgender are not at all interchangeable states of being, society would make significant progress if it treated both objectively as medical conditions rooted in biology. 

I love science and capitalism because they are both based in reality. Objectivism is the idea that truth is not relative, that things are what they are. I was born with a disorder — a deviation from normal physiology that created a serious problem. Medicine solved my problem, just as it has for so many other maladies. The solution to the “transgender problem” is to depoliticize it and treat patients with compassion, an open mind, and science.

Anonymous MD is a physician, husband, and father. He is a self described free market capitalist and believes in small-government, evidence-based solutions. 

References

1. Mueller, et al. The Neuroanatomy of Transgender Identity: Mega-Analytic Findings from the ENIGMA Transgender Persons Working Group. J. Sex Med. 2021 Jun; 18(6): 1122-1129. https://pubmed.ncbi.nlm.nih.gov/34030966/
2. Bakker, J. Brain Structure and Function in Gender Dysphoria. Endocrine Abstracts (2018) 56 s30.3. https://www.endocrine-abstracts.org/ea/0056/ea0056s30.3
3. Xerxa, et al. Gender Diversity and Brain Morphology among Adolescents. JAMA Network Open. 2023; 6(5):e2313139. https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2804855
4. Hoekzema, et al. Regional Volumes and Spacial Volumetric Distribution of Gray Matter in the Gender Dysphoric Brain. Psychoneuroendocrinology. 2015 May:55:59-71. https://pubmed.ncbi.nlm.nih.gov/25720349/
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6. Swaab, Garcia-Falgueras. Sexual Differentiation of the Human Brain in Relation to Gender Identity and Sexual Orientation. Funct Neurol. 2009 Jan-Mar; 24(1): 17-28. https://pubmed.ncbi.nlm.nih.gov/19403051/
7. Ruble, et al. The role of gender constancy in early gender development. Child Dev. 2007b; 78:1121-36. https://pubmed.ncbi.nlm.nih.gov/17650129
8. Singh, et al. A Follow-Up Study of Boys with Gender Identity Disorder. Front. Psychiatry. 2021 March;Vol 12. https://www.frontiersin.org/journals/psychiatry/articles/10.3389/fpsyt.2021.632784/full
9. Steensma, et al. Factors associated with desistence and persistence of childhood gender dysphoria: a quantitative follow-up study. J Am Acad Child Adolescent Psychiatry. 2013 Jun;52(6):582-90. https://pubmed.ncbi.nlm.nih.gov/23702447/
10. Wanta, et al. Mental Health Diagnoses Among Transgender Patients in the Clinical Setting: An All-Payer Electronic Health Record Study. Transgend Health. 2019; 4(1):313-315. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6830528/
11. Frew, et al. Gender dysphoria and psychiatric comorbidities in childhood: a systematic review. Australian Journal of Psychology. 2021, Vol73 – Issue 3. Pp 255-271. https://www.tandfonline.com/doi/full/10.1080/00049530.2021.1900747
12. Van der Loos, et al. Bone Mineral Density in Transgender Adolescents Treated with Puberty Suppression and Subsequent Gender-Affirming Hormones. JAMA Pediatr. 2023; 177(12):1332-1341. https://jamanetwork.com/journals/jamapediatrics/article-abstract/2811155#xd_co_f=NjEwZjA5OWItZGMzMC00MWMxLThmM2ItYTliYTQyN2VkODEw~
13. Staphorsius, et al. Puberty suppression and executive functioning: An fMRI-study in adolescence with gender dysphoria. Psychoneuroendocrinology. 2015 Jun: 56:190-9. https://pubmed.ncbi.nlm.nih.gov/25837854/
14. Mahfouda, et al. Puberty suppression in transgender children and adolescents. The Lancet: Diabetes and Endocrinology. 2017 Oct Vol 5(10) p 816-826. https://www.thelancet.com/journals/landia/article/PIIS2213-8587(17)30099-2/fulltext
15. Providing Ethical and Compassionate Health Care to Intersex Patients. 2018. https://interactadvocates.org/wp-content/uploads/2018/09/interACT-Lambda-Legal-intersex-hospital-policies.pdf