Questioning transsexuality
<p>In <a href="http://www.nationalreview.com/article/356501/bradley-manning-not-woman-kevin-d-williamson">Bradley Manning Is Not a Woman</a>, Kevin Willamson makes a case that feeling like a transsexual &#8211; that is, that one is either a man in the body of a woman or vice-versa &#8211; should be regarded as a mental illness to be treated by therapy rather than with sex-reassignment surgery.</p>
<p>The article surprised me by presenting a coherent case for this position that I cannot dismiss as garden-variety social-conservative chuntering.  I found the parallel with what Willamson calls BIID particularly troubling.  If we treat people who desire to electively amputate their own arms and legs as mentally ill, why do we judge people who want to amputate the genitals they were born with any differently?  What makes one an illness and the other a lifestyle choice?</p>
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<p>As a libertarian I&#8217;m inclined to think that people have a right to mutilate their own bodies any way they like, provided that the surgical and after-care costs aren&#8217;t forcibly extracted from anybody else.  But libertarian respect for autonomy cannot entirely banish the concept of mental illness either.  Some people have minds that are broken and need treatment; respecting their autonomy too much to deliver treatment condemns them to lives full of needless and avoidable pain.</p>
<p>In the rest of this essay I&#8217;m therefore going to ignore, on purpose, the question of how to reconcile libertarian values with a theory of mental illness.  I feel justified in this by a particularly interesting feature of Willamson&#8217;s argument.</p>
<p>Williamson&#8217;s contribution is to show that it&#8217;s quite difficult to construct a theory of &#8220;mental illness&#8221; that includes BIID but excludes transsexuality.  Given the high frequency with which post-op transsexuals commit suicide, Willamson even could have argued that people with BIID are <em>less</em> ill than transsexuals, evidenced by the fact that they&#8217;re less self-destructive.  Tellingly, suicide rates are not significantly lower among transsexuals who cannot get reassignment surgery.</p>
<p>Thus: if libertarians are going to have a theory of mental illness at all, we will be required to grapple with the philosophical issues raised by transsexuality in the same way as non-libertarians for whom &#8220;mental illness&#8221; is a much less fraught and suspicious concept.  And that is he last thing I will have to say about libertarianism here.</p>
<p>I&#8217;ve known two transsexuals well enough to believe I have some idea of what their inner life is like; I&#8217;ve met, I think, four others.  I&#8217;ve felt sympathy for all of them &#8211; but Willamson reminds me that sympathy may be as easy but serious a mistake here as it would be with respect to a paranoid schizophrenic. (This is my thinking, not his; Williamson never discusses paranoid schizophrenics or whatever the DSM is calling them this week.)</p>
<p>How is Bradley Manning&#8217;s expressed belief that he is a woman trapped in a man&#8217;s body epistemically distinguishable from a paranoid schizophrenic&#8217;s belief that (say) he is pursued by invisible demons who compel him to burn his own flesh?  I&#8217;m a predictivist and judge truth claims by how they cash out as observations of future events; what Williamson forces me to recognize is that  I can&#8217;t really formulate a consequential test for <em>either</em> claim.</p>
<p>Furthermore, I can&#8217;t trust what the &#8220;transsexual&#8221; Bradley Manning tells me about his situation any more than I can trust what the demon-haunted paranoid tells me about his. In neither case are the referents of their claims located anywhere but inaccessibly within their own skulls. </p>
<p>Accordingly, I can&#8217;t find principled grounds to classify one as a delusional system and the other as not.  Now, one might say: there are no such things as invisible demons!  But: where is the evidence that there is any such thing as &#8220;women trapped inside mens&#8217; bodies&#8221; or vice-versa? </p>
<p>Willamson reminds us that the concept of a psychological gender identity separate from one&#8217;s physical one actually has about the same confirmation status as invisible demons.  The only warrant for it is a gallimaufry of speculation based on reports from a population that by objective measures seems to be highly disturbed and dysfunctional (and the 18-20% suicide rate is only the the most obvious indicator).</p>
<p>So, why do we <em>not</em> treat self-reported transsexuals as insane and in need of treatment for a delusional disorder?  I can anticipate a lot of possible replies; the trouble is that all of them apply just as well (or just as poorly) to the case of BIID or delusional paranoia.</p>
<p>One of the stupidest possible counters is also probably the most common one: if you don&#8217;t accept transsexuals&#8217; reports of their own condition, you&#8217;re being nasty and unfeeling to them. Um, OK, how does this apply to paranoids? Am I required to believe in invisible tormenting demons on pain of being considered cruel to those people?</p>
<p>Another, possibly even stupider argument is that if I don&#8217;t believe that physiological and physical gender identities can be opposed I am taking the side of Bad People &#8211; conservatives, phallocrats, whatever. I don&#8217;t really see this as being any different than the religious argument my ancestors might have been given for the existence of invisible demons.  It&#8217;s just as obviously fallacious.</p>
<p>Back in more religious times, belief in invisible demons was not helpful to people we would now categorize as delusional paranoids; a hefty dose of Thorazine, while not a cure, at least manages their condition, bringing down the incidence of suicides and self-mutilation and other violence.  </p>
<p>I don&#8217;t actually see, now that Williamson has slapped me upside the head enough so I notice the issue, that a belief in separated psychological and physiological sexual identities is any more helpful to transsexuals.  The objective check is that acting on this belief doesn&#8217;t seem to reduce their suicide rates significantly.</p>
<p>First, do no harm. We&#8217;ll know we have a rationally and ethically sound way of handling &#8220;transsexuality&#8221; when we find one with sequelae significantly less grim than doing nothing.  Right now, gender reassignment surgery doesn&#8217;t qualify &#8211; Williamson quotes a British research group affiliated with NHS reporting “no robust scientific evidence that gender reassignment surgery is clinically effective.” </p>
<p>I think Williamson is right that it&#8217;s time to be much more critical about the theory and ideological fashions that led us to where we are now.  A good place to start would be to ask how we might establish that &#8220;transsexuality&#8221; exists and what it means, after applying the same skepticism that we do to self-reports by other people who report an urge to lop off their body parts.</p>
