Last week the World Professional Association for Transgender Health released an advance copy of its revised guidelines for transgender health care. The guidelines are to be published in a medical journal soon.
Among the guidelines is the recommendation that medical gender transition treatment could be done at a younger age: 14 years old for some hormone treatments; 15 or 17 for certain surgeries.
We know from numerous reports that the guidelines are controversial, not just among parents and activists, but among the members of WPATH themselves. That is unsurprising, because the guidelines reflect an attempt to establish a policy within a social context in which every choice of terminology and every study cited is subject to dispute.
A complicating consideration is the fact that of the estimated 1.6 million Americans who identify as transgender, a large and rapidly increasing proportion of them are under age 18. But most of what researchers know about whether a person is likely to regret engaging in irreversible treatment comes from studies of people who transitioned after age 18.
WPATH appears to have framed their decision in a fairly straightforward utilitarian way: Will it cause less pain and suffering overall to allow gender-affirming treatment at a younger age with the result that some might later regret their decision, or will it be worse to delay that treatment which may cause harm to those who have to wait?
I do not have any special expertise in this area, so I will not take issue here with the new guidelines themselves. However, as an ethicist, I have two significant concerns about the way the debate is being framed, both within WPATH and within our greater cultural context.
My first concern is the use of suicide as the chief justification for gender-affirming treatments at a young age. The underlying assumption is that suicide is a predictable response to extreme suffering, so if a certain set of conditions result in higher suicide rates (or increased thoughts of suicide), then that is a good indication those conditions contribute to extreme suffering.
The threat of suicide is then used by pro-transitioning advocates to pressure parents into consenting to gender-affirming treatment for their child. Reporter Emily Bazelon notes that while researching her recent New York Times Magazine story on gender therapy, “[m]any parents told me they’d heard the mantra: ‘It’s better to have a live son than a dead daughter.’”
It is not just parents who hear this. Listen sometimes to how adolescents talk to one another about the dangers of non-conformity. Suicide seems to have become the new norm for responding to all kinds of social rejection.
We know from repeated studies about social norms that the expectation that a certain behavior is a typical response to a set of conditions makes it more likely that people will act that way under those conditions. Is the constant talk about suicide among transgender youth one of the chief reasons suicide attempts are rising among that population?
Suicide is not a health effect, it is a behavior. But we constantly talk as if suicides “result” from exposure to negative experiences in the same way that cancer results from exposure to toxins. Talking that way is not only careless, it is dangerous and irresponsible.
My second concern is the easy assurance with which so many talk about choosing one’s identity and the assumption that the biggest challenge is overcoming resistance to social expectations. LGBTQ activists often speak blithely about society moving beyond our cisgender norms, as if that would remove any obstacles to everybody being able to live a more satisfying life of their own choosing.
But we don’t know how much our individual and social well-being actually depends upon having a stable and reliable social context, certain forms of life that one can just fall into, as it were, without having to explicitly choose them. Bearing the weight of responsibility for choosing every aspect of one’s identity can be a terrifying prospect to many. It is not even clear that such a life would be possible.
Immanuel Kant wrote of a dove, feeling the resistance against its wings as it flies, imagining how much easier it would be to fly in empty space. Of all the various deceptions and misconstruals to which one can fall victim, the most pernicious is the conviction that it is easy to know oneself if only one could be rid of all outside influences.
The difficulty of knowing who we are is so great because human beings live in a world comprised of natural limits while also possessing an imagination that has relatively few such limits. The life we create for ourselves is always something of a compromise among what we can imagine, what we are able to do and what society expects of us.
Young people who are questioning their gender identity need above all two things from the communities in which they live.
They need to know that the value of their life lies beyond the specific choices they make and beyond the way others might perceive them. Each life is worthy of love and respect, and they should be encouraged to feel their self-worth deeply and consistently.
They also need a circle of support comprised of people who are humble enough to listen to them and help them ask the questions that may deepen their understanding of their place in the world. That’s something we all need.