Controversial legislation allowing self-selected use of public bathrooms by transgender individuals has sparked much discussion about how we determine policies to protect public safety, yet meet appropriate needs for those individuals whose birth certificate sex designation may differ from the gender role they have assumed later in life.
Medically, gender refers to our biological sex as determined by our two “sex” chromosomes, one from each parent. Two X chromosomes determines a biological female, while one X and one Y chromosome determines a biological male. The Y chromosome can only come from the child’s father.
In the 20th century, however, “gender” has moved beyond biology, morphing into a new construct that is part socio-cultural, part ideological and part political: that gender is based on one’s self-perception of being male or female.
Therein lies the crux of the problem. “Social equality” activists believe that one’s feeling of gender cannot be questioned by the rest of society and that policies should be made according to the individual’s assumption of gender rather than biological sex. Such self-perceptions are rarely considered the criteria used for decision-making in other areas of medicine, psychiatry, or social policy. To do so across the board would result in chaos.
In medicine and psychiatry/psychology, we recognize that self-perception may be distorted and not consistent with observable phenomena. False self-perceptions or assumptions can have serious, and possibly lethal, consequences. Consider these common examples in medicine:
- An alcoholic has self-perception that he/she is sober, then decides to drive while legally intoxicated, crashes into another car and kills a entire family.
- A diabetic has a self-perception that blood sugars are normal, doesn’t check or treat them and then falls into a coma from either hypo or hyperglycemia.
- A patient with high blood pressure has self-perception that his blood pressure is “normal,” doesn’t check or treat it, then has a stroke due to severe hypertension.
- A young woman with anorexia nervosa has self-perception that she is grossly fat, yet has lost so much weight that she dies from malnutrition.
- A young man with body dysmorphic disorder has a fixed self-perception that he is “grossly ugly” and commits suicide, in spite of appearing to be a normal, good-looking young man.
All of these situations are disorders of assumption, in which the assumption or self-perceived condition is factually incorrect. I think most people would agree that the individuals described above, all too common in medical practice, should be helped with treatment, not allowed to continue in their detrimental self-perception. As medical professionals, our job becomes helping that person’s self-perception match the medical reality so that proper therapeutic interventions may be offered and lives spared.
Transgender patients, who make up 0.3 percent of the U.S. population, have a similar disorder of assumption. If public policy allows them to designate their sex based on self-perception, it creates a situation where actions of a small minority jeopardize safety of the majority. Activist groups disagree with this view and strongly advocate for individual self-perception to be accepted as medical and legal reasons for using the bathroom of one’s choice. But statistics for sexual crimes, overwhelmingly affecting women and girls, show that is not sound or safe public policy.
As a scientist-physician trained in biology, medicine and psychiatry, and one who has treated transgender patients, my focus is primarily the scientific medical-psychiatric aspects rather than moral. Our goal should be to “do no harm” in our treatment. Long-term studies show that sex-reassignment surgery for transgender patients does not improve psychological-emotional distress over time, compared to those who have no surgery. Evidence thus suggests an underlying mental disorder and that treatment should be focused on that, rather than accepting “feelings” of different gender, “normalizing” the behavior and blithely thinking surgery “fixes” the problem.
Making things worse
One of the largest and longest studies was published in 2011. The Karolinska Institute in Sweden followed 324 individuals after sex-reassignment surgery for up to 30 years. Researchers found an alarming 20-fold increase in death by suicide among the transgender individuals compared to non-transgender population, and that about 10 years after the sex-reassignment surgery, transgender individuals began developing higher rates of mental disorders, such as depression. Surgery did not improve the underlying emotional-psychological issues that needed treatment, leaving patients tragically vulnerable to an extraordinarily high rate of later suicide.
Johns Hopkins, the first American medical center to perform gender-reassignment surgery and to have a comprehensive team evaluation and treatment program, developed an outcomes study starting in the 1970s to evaluate post-surgical psycho-social adjustment. The Hopkins study found no better psychological outcomes for the group that had surgery vs. those who did not. The Hopkins team decided to stop performing high risk sex-reassignment surgeries that had no long-term benefit over no surgery.
Clearly, there are problems with a perception-based definition in thinking that gender can be changed when it is a biological construct. It is perception that is changeable, not one’s gender or biological sex. Perception of reality is the purview of psychiatry and psychology, and sound therapeutic approaches, in view of the studies above, are often more appropriate interventions than sex-reassignment surgery. Even with surgery, transgender men are still biologically male even though they have assumed the social role, dress and hormones of a woman. For example, even if taking hormones to maintain a feminized body, transgender men still have an XY chromosome makeup and need prostate monitoring for later cancer.
Activists who fail to consider empiric evidence and ignore the reality of suffering and anguish demonstrated by long-term studies cause damage to many lives when the wrong treatment is implemented for transgendered individuals.
Politically, surgical treatment of gender disorders is presented as a simple thing to do. Activists claim that narrow-minded physicians or moralists stand in the way of patients getting their wishes met. The reality is quite different.
As a medical student, I scrubbed in on such surgeries. Over my career, I have treated a number of patients who have had it done. Gender reassignment surgery is lengthy, complex and requires many surgeries to accomplish the gender change. It carries higher than usual surgical risks in part because of the complexity and length of the procedures. Patients going through it must endure long, painful recoveries. Such surgeries are exceedingly expensive, whether borne by the individual, private insurance or taxpayer-funded insurance (Medicare, Medicaid, TriCare).
Based on the self-perception of needing surgery, patients are now demanding it is their “right” for Medicare and private insurance to pay for their gender-reassignment surgery. Giving in to activists’ demands, Medicare ruled in 2014 that it would pay for surgical costs for those over 65 who perceived they were males “trapped” in female bodies or females in male bodies. Pfc. Bradley (now Chelsea) Manning was in the national headlines for his sex change surgery after he was charged for crimes of leaking classified documents, found guilty and imprisoned. Taxpayers bore the cost of his sex-reassignment surgical procedures.
How does this fit with other medical situations currently covered by Medicare? Patients are finding more and more that their self-perception of need for a particular medication or surgical treatment, and even their doctor’s perception of need for such treatment, medication or surgery, does not agree with the guidelines decided by bureaucrats in Washington. Here are some examples my own patients have encountered:
- In 2015, Medicare stopped paying for estrogen therapy for women and testosterone for men 65 or older, based on arbitrary cost-saving decisions rather than patient or physician perception of need and benefit.
- Medicare has reduced payments for hospice care, home health care, physical therapy and hospital re-admissions within 30 days of discharge (even for seriously ill patients with life-threatening relapses).
- Budget cuts have also made it more difficult for physicians to obtain approval for Medicare payment for hip, knee, shoulder and back surgeries.
These reductions in Medicare benefits affects all beneficiaries 65 and older, and were implemented one year after Medicare decided to expand use of its limited funds to pay for gender reassignment therapy for less than 0.1 percent of Medicare patients.
How many prescriptions could be covered for how many thousands of patients for the cost of ONE sex-reassignment surgery for a transgender patient?
“Feel good” bureaucrats and politicians who implement social policy based on flawed assumptions, yet are unaccountable for their decisions, also create situations in which both the individual and the public safety is jeopardized.
Social engineering based on policymakers’ ideology instead of reality jeopardizes the safety of women and girls in public bathrooms. This transgender bathroom controversy is not about “human rights” – it is out of control political agendas putting other people’s safety and privacy at risk.
We cannot just accept an individual’s self-perception about bathroom choice when it may endanger others. America needs common-sense policies for safety for the majority. Keep it simple: parts is parts: If you have female parts, use women’s bathrooms; if you have male parts, use men’s bathrooms.
Here’s the help you’ll need to prepare your household for the realities of living under a centralized health-care system — order “Surviving the Medical Meltdown: Your Guide to Living Through the Disaster of Obamacare”