Saturday, April 8, 2017

Glenn Stanton: Gender Dysphoria is Identical to Body Integrity Disorder - UPDATED

These straw men take on a familiar shape
UPDATE, April 8, 2017: This piece was originally published on April 4. A reader with BIID wrote to me with some worthwhile counterpoint. I agree in part and disagree in part. I have added those comments, unedited, at the end.

Glenn Stanton, of Focus on the Family, claims that a woman who wants her spinal cord severed is the same thing as a transgender individual seeking gender-affirming surgery. His new post at The Federalist is titled “Woman Demands Doctors Sever Her Spinal Cord To Align Body To Mind, ‘Same As A Transsexual Man’.” He really did write that. The subtitle reads “Let’s examine gender dysphoria, the underlying condition of identifying as transgender, with a similar but different body identity problem.”

Regarding Mr. Stanton:

Some digression is in order as Stanton writes many stunningly stupid things. Please bear with me. Stanton's spécialité is to either claim that research says what it doesn't or to uncritically accept research that he likes. For example with some subtlety he claims that this study (on page 170 [he is specific]) reveals that the children of gay parents are more likely to be gay when, in fact, the authors were critiquing a different, older study. 

Stanton had no problem, whatsoever, accepting the outlandish claims of Douglas Allen, a Canadian economist at Simon Fraser University positing that children raised by gay couples are only about 65 percent as likely to have graduated from high school. This, of course, was based, not on research, but on a literature review that was published to a home economics journal. None of these things, plus the fact that an economist was challenging a considerable body of research by sociologists caused Stanton any concern. It said what he likes as a conservative Catholic thus it must be true.

In the same polemic, Stanton either did not read in full, did not understand or mischaracterized Mark Regnerus' 2012 New Family Structure Study. As a reminder, this “research” was funded by the ultra-conservative-Catholic Witherspoon Institute specifically to affect the Supreme Court's 2013 deliberations in United States v. Windsor and Hollingsworth v. Perry.

For example, Stanton asserts with relish: “ Twenty-five percent of the kids raised by gay fathers reported having a sexually transmitted infection at some point, as did 20 percent of those raised in lesbian households and 8 percent raised by their married biological parents.” Gay fathers? Lesbian households?

The subjects of the Regnerus study were adult children who claimed that one of their parents had an extra-marital affair with someone of the same sex. To some degree they were possibly bisexual people. Essentially, though, Regnerus compared dysfunctional families with the Cleavers. Which group would be healthier?

Let us return to the current “straw man.”

The notion that transgender people are no different from people with oddities like some form of body dysmorphic disorder is not terribly original in Christendom nor novel. Stanton writes:
An effective way to determine the fundamental nature of a thing is to compare it with something that is similar, but different. For example, what is an oval? It’s an elongated circle. Let’s examine gender dysphoria, the underlying condition of identifying as transgender, with a similar but different body identity problem.
Stanton is positing something that is quite extreme (voluntary paraplegia). Putting forth an extreme argument that is easy to argue against is the very definition of the logical fallacy known as a straw man argument. Moreover, Stanton wants to pass off a form of body integrity identity disorder (BIID) as similar to gender dysphoria (GD). They are as similar as door knobs and thermostats.

Just for starters, BIID is, well, a disorder that is treatable through therapy. GD is not a disorder and there is no known therapy that has any effect on the condition. Somewhere between 0.3% and 0.6% of the population are transgender. That amounts to one million to two million people in the US. Substantially more people have GD to some degree. How many people does Stanton think want to paralyze themselves? Nationwide? Three?

Stanton is amazing:
… being transgender is only one subset under a larger condition. While many trans advocates resist the categorization, it falls practically under the category of what psychologists term Body Integrity Identity Disorder (BIID). It’s a general condition where a person’s physical body does not align with or is dis-integrated with what his or her mind understands itself to be. It’s psychological Platonism.
Rubbish. Utter nonsense. Body integrity identity disorder (or amputee identity disorder) is a psychological disorder in which an otherwise healthy individual feels that they are meant to be disabled. Now some people who have BIID compare themselves to transgenders but that is not a professional construct. “Platonism” in that context is ambiguous. Sorry, Glenn. You are simply not that smart.

Skipping past more attempts to compare a disorder (BIID) in its various forms with a condition (GD):
Why Can Transsexuals Cut Off Body Parts But Not Others?

Some with this condition refer to themselves as transabled. They “know” their true essence is not just being free of a particular limb, but actually being a disabled person of some sort. Some feel they are truly a blind person, but are living with the unacceptable “burden” of working eyes. For some, it’s hearing.
Other than continuing the straw man comparison, I fail to understand the purpose for that question. It it a rhetorical device to assert that gender-affirming surgery should be unavailable? Here is an abstract from the highly respected American Journal of Bioethics.
The term body integrity identity disorder (BIID) describes the extremely rare phenomenon of persons who desire the amputation of one or more healthy limbs or who desire a paralysis. Some of these persons mutilate themselves; others ask surgeons for an amputation or for the transection of their spinal cord. Psychologists and physicians explain this phenomenon in quite different ways; but a successful psychotherapeutic or pharmaceutical therapy is not known. Lobbies of persons suffering from BIID explain the desire for amputation in analogy to the desire of transsexuals for surgical sex reassignment. Medical ethicists discuss the controversy about elective amputations of healthy limbs: on the one hand the principle of autonomy is used to deduce the right for body modifications; on the other hand the autonomy of BIID patients is doubted. Neurological results suggest that BIID is a brain disorder producing a disruption of the body image, for which parallels for stroke patients are known. If BIID were a neuropsychological disturbance, which includes missing insight into the illness and a specific lack of autonomy, then amputations would be contraindicated and must be evaluated as bodily injuries of mentally disordered patients. Instead of only curing the symptom, a causal therapy should be developed to integrate the alien limb into the body image.
Again, it is BIID advocates (not the professionals) who are making a comparison to gender-affirming surgery and the comparison is to treatment in contrast to the underlying condition. The second highlighted portion is unique to BIID does not apply to gender dysphoria.

The bottom line to all of this is that we can rationally support gender-affirming surgery while, perhaps, opposing voluntary amputations because the underlying conditions are so profoundly different. However, Stanton knows his incurious and simplistic constituency and they are likely to apply similar constraints.
Chloe Jennings-White is very capable and well-accomplished, a research scientist with degrees from Cambridge and Stanford. However, she “knows” she is also a paraplegic, even though fate has dealt her fully functioning legs.
She says it’s not that strange, but “the same as a transsexual man having his penis cut off. It’s never coming back, but they know it’s what they want.” Why him and not her?
It is a rhetorical question that I leave to her doctors. However, it does not address the appropriateness of gender-affirming surgery. If anything Stanton inadvertently assumes that transgender surgery is medically proper. Stanton is trying to change the question from what it is to what it isn't. The intended inference is: If BIID surgery is improper then why is gender-affirming surgery not improper? It is rhetorical nonsense because the underlying conditions are so dissimilar. And voila:
Trans advocates resist this comparison, claiming these are very different things. How? Well, they say one is made up and the other is real. They say one is a severe psychosis and one is natural. Can you guess which evaluations apply to which condition? It is a convenient way to understand the two if you’re transgender, but are they really that different? Researchers who study these individuals report they rarely demonstrate any other type of psychosis beyond this condition.
Stanton is arguing with a blog post about body dysmorphic disorder vs. gender dysphoria. Which comparison? Treatment or condition? I really do not care about the comparison by a Jezebel contributor. According to the professionals BIID is a disorder while GD is a condition. BIID has a neurological correlate. GD does not. Surgery for BIID results in a possibly catastrophic impairment. Gender-affirming surgery does not impair the patient. Furthermore there is no progressive way to sever one's spinal cord. Before people are candidates for gender-affirming surgery they receive hormones and live according to their gender. There is some certainty that the surgery will improve their lives. There is no way for someone to experience paraplegia in advance.

This all continues ad nauseum. Stanton asks:
Does Body Cutting Help These Sufferers?

Now, to the most important question, because this involves real, hurting human beings: Does the cutting help? Few would agree that cutting off a perfectly healthy limb or severing spinal nerves is the compassionate and sensible solution for the transabled person. But is it different for the transgendered person?

A 2011 Swedish study, a long-term follow-up of men and women who underwent gender reassignment surgery, indicates that cutting bodies and administering hormonal treatments are not as ameliorative as many think. The authors carefully explain the methodological problems that have plagued previous analyses and how their study provides marked improvements.
Stanton fails to note that the study might have been in 2011 but the subjects had surgery between 1973 and 2003; from 14 to 44 years ago. Just over the last five years alone there have been dramatic changes in attitudes. In 1973 those people were regarded as freaks. One of the things that I noticed is this:
Transsexual individuals had been hospitalized for psychiatric morbidity other than gender identity disorder prior to sex reassignment about four times more often than controls.
I doubt that would be true today. Furthermore we do not know the age distribution at the time of surgery. The average age at the time of surgery was 35. That is quite advanced by today's standards. Younger patients (no — not children) do much better and their transition is cosmetically much better. Stanton loves partial or selective observation of research:
In contrast to the general population in Sweden, those who have undergone sex reassignment surgery in that extremely gender-variant country are:
  • Three times more likely to die prematurely from any cause.
  • Nineteen times more likely to die from suicide.
  • Three times more likely to die from cardiovascular disease.
  • Three times more likely to require psychiatric hospitalization.
  • Two times more likely to engage in substance misuse.
  • Two times more likely to commit violent crime.
Stanton is using the crude ratios rather than the adjusted ratios which are slightly lower. What he is suggesting is that these results are due to the surgery (again, in some cases more than 40 years ago). The comparisons are to the general population but you do not have to take my word for it. The conclusion of the researchers:
Conclusions: Persons with transsexualism, after sex reassignment, have considerably higher risks for mortality, suicidal behaviour, and psychiatric morbidity than the general population. Our findings suggest that sex reassignment, although alleviating gender dysphoria, may not suffice as treatment for transsexualism, and should inspire improved psychiatric and somatic care after sex reassignment for this patient group.
In other words, the surgery helps but more care is required after surgery. Stanton didn't read that part or chooses to ignore it.
Surgery Does Not Address the Psychological Problems

The eminent Paul R. McHugh directed the Department of Psychiatry and Behavioral Sciences at Johns Hopkins University and was psychiatrist-in-chief at Johns Hopkins Hospital for more than 25 years. …
No reason to repeat the assertions of a Defender of the Faith and known quack. The reaction of 600 scientists who reached the point of “we have had quite enough of Dr. McHugh” should suffice.

Stanton finally reaches a conclusion:
We must understand that both of these are severe psychological conditions and must be treated compassionately but truthfully. The fact that high-profile professional psychiatric associations say one of these is no longer a psychological disorder must be taken with a substantial grain of salt. Their conclusion is not the result of any new scientific development. It’s the admitted result of significant pressure by pro-transgender lobbyists.
That first cite is to the APA, the second to the Advocate and he is being misleading. The fact that there was advocacy to change gender dysphoria from a disorder to a condition does not mean that the change was inappropriate or unwarranted.
Patients are seldom well-served by ideology and beliefs crafted from political expediency. For their sakes, we must be honest about what we are dealing with here, and the similarities between these two conditions should be instructive.
I have behaved myself thus far. I am entitled to one “bullshit!” Stanton is not a scientist. Nor does he really have an interest in the wellbeing of transgender people or people with gender dysphoria. At Focus on the Family, he refers to these conditions as “gender confusion.” No psychologist or psychiatrist would ever do that. Well, maybe McHugh but not many more. Confusion is what this ignoramus is telling parents and, sadly, some are inclined to believe him. Yet the confusion belongs to Mr. Stanton and it is willful.

Stanton is a conservative Christian who is employed by a conservative Christian political organization seeking to impose conservative Christianity on public policy. Everything that Stanton says or writes is ultimately about his religious beliefs no matter how secular he tries to make things sound. Religion has no part in the treatment of cancer. It has no part in the treatment of gender dysphoria for religion provides us with a deliberately uninformed voice. I want my doctors to consult the medical literature, not scripture.

Feedback from a reader with BIID:

"Condition" versus "disorder". "Disorder" versus "dysphoria". I think you are nearly as guilty of being arbitrary with language as this Glenn Stanton you criticize.

GD is still legitimately called GID, Gender Identity Disorder, by many people. You could say it is a disorder because medical intervention (hormone therapy, surgery) treats the dysphoria. You can easily imagine calling BIID "Body Integrity Identity Dysphoria" instead of "Disorder". The dysphoria felt and the longing to be in the correct body are similar according to those that suffer from both conditions. Yes - there are people with both.

You wrote "BIID is, well, a disorder that is treatable through therapy," but so far the only documented successful treatment for BIID is surgery to remove the offending limb. For those with BIID that do not want an amputation but want paralysis or blindness or deafness there are fewer options and fewer published examples, but there are clues: the woman who blinded herself and is now happy and people who had accidents resulting in paralysis and find themselves cured of their BIID.

I agree that GD and BIID are different. I also agree that the religious right shamelessly uses BIID, a highly stigmatized condition, as a straw man to attack GD, an only recently much less stigmatized condition. Many of us with BIID are inspired by the dramatic growth in acceptance that transgenderism has experienced. Maybe someday BIID will also be more accepted? I think a decline in misogyny and increased tolerance of the spectrum of sexual orientations and gender identities has contributed to the growing support for transgender people. Will a decrease in ableism allow for something similar with BIID? I know I'm not the only one who hopes so . . .

You flippantly write, "How many people does Stanton think want to paralyze themselves? Nationwide? Three?" How many people had GD 50 years ago? 100 years ago? No one really knows. Similarly, today no one really knows how many people have BIID. BIID is so stigmatized it is hard to admit that you have it to yourself, let alone to the wider world. I know I am one of many, at least dozens, nationwide who want to be paralyzed. Dozens is based on people I have met or read about via the internet. I suspect the actual numbers could be significantly higher. Nonetheless I do think BIID is rare - probably rarer than GD, but not as rare as you think.

Further stigmatizing BIID and denying the parallels between BIID and GD does not lessen the impact of the right's straw man argument. It actually strengthens it by weakening your own. GD and BIID are different conditions. The fact that intervening surgically to treat BIID results in someone with a disability raises questions of ethics and autonomy and the common good that are different from the issues raised by intervening medically and surgically to treat GD. Nonetheless, the many parallel issues should prompt empathy and solidarity rather than ridicule.

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