Transgender Delusion

Human nature does not change. Despite our postmodern sophistication and our wishful thinking about perfectibility, our nature is immutable—not least in its fickleness, its embrace of irrational ideas and practices, and its suggestibility.

Charles Mackay’s classic work, Extraordinary Popular Delusions and the Madness of Crowds (1841), chronicles the fads and follies of humankind, our epidemics of irrational groupthink. It illustrates our enduring credulity, covering such follies as alchemy, financial bubbles, the Crusades, fortune-telling, false prophesy, witchcraft, and witch hunts. Mackay’s account of the Dutch tulip mania, in which people lost fortunes by bidding up the price of tulip bulbs to ridiculous levels, anticipates the recurrent cycles of boom and bust that have plagued nations’ economies since his book was first published. Such hysterical contagion continues in modern times, merely taking on new forms.

The medieval field of alchemy—the attempt to change base metals into gold and to find the philosopher’s stone capable of bringing about human perfection, even immortality—is ludicrous to the modern mind, a relic of a prescientific time. Yet the ancient belief in transmutation is still with us. Current popular delusions are aspirations not to turn base metals into gold, but rather to transcend the laws of biology and transmute human nature. Among them is the popular belief that gender is fungible, so that whether we are born male or female is of no consequence.

Popular delusions are usually false beliefs that fly in the face of common sense, rational thinking, and even scientific evidence. When the delusional group is small and composed of socially marginalized people with an impoverished sense of self, who relinquish personal autonomy to a charismatic and mentally unstable leader (such as occurred in the 1978 Jonestown, Guyana, mass suicides), there is little danger of delusional contagion beyond the cult. By contrast, during the widespread “satanic ritual abuse” hysteria of the 1980s, people believed bizarre accusations of child abuse, which were being­ ­perpetuated by credulous social workers and ­psychotherapists. Innocent people were prosecuted and jailed. ­Similarly, the recovered-­memory hysteria, in which false “memories” of ­childhood sexual abuse ruined the lives of ­alleged abusers, was fostered by mental health professionals—the very ­people who should have known better.

Now consider one of our current popular delusions: that gender is a social construct rather than a biological fact. This is the notion that there are no biologically determined characteristics of either sex—that “male” and “female” are socially assigned roles. According to this worldview, a person is not simply male or female. In fact there are no “opposite sexes,” only a gender spectrum between femaleness and maleness (hence the prefix “trans-” in “transgender”), and one may choose to identify oneself with any point on the continuum, or to remain undecided.

This delusion has infected groups that are presumed to be the most highly educated, sophisticated, and worldly-wise in our society. Its contagion to elite academia was exemplified in 2005 after Lawrence Summers, in a thoughtful and nuanced speech, suggested that perhaps one of the factors behind the underrepresentation of women in science and engineering is a natural difference in aptitudes. He even prefaced his remarks with what is now called a “trigger warning” for fragile sensibilities, to the effect that he was attempting to provoke a discussion. But the storm of hysterical outrage that followed drove him from the presidency of Harvard.

Another manifestation of denial of the biological differences between the sexes takes the form of a man’s declaring, in effect, “My gender is what I say it is. I feel like I’m a woman in a man’s body, and I demand that I be treated like one.” The demands that society accommodate such absurd personal delusions are becoming ever more aggressive. We see municipal and school authorities, for example, scrambling to mediate conflicts about gender-neutral bathrooms and shared locker rooms, fearful of being labeled as bigots, or sued, if they do not comply. If someone wonders whether a middle-aged man who declares that he is a woman and demands the use of public female restrooms might be mentally disturbed, that doubter had better not voice her concern publicly; she risks not only being labeled a bigoted denier of civil rights but also having her business boycotted.

The mainstream media falls in line by developing a new lexicon of gender-neutral nouns and pronouns to label adequately the whole range of the gender-dissatisfied—from the merely questioning, through the transitional, to those who have had a sex change operation (or “gender reassignment”). Editorializing on the transgender phenomenon, the New York Times used anecdotal testimonials to present sex-change surgery as the restoration of a civil right to people long deprived of their authentic selves. The entire spectrum of gender dysphoria disorders is treated as though it were an authentic lifestyle choice unreasonably suppressed by a bigoted majority.

My profession—psychiatry—has reacted with the most egregious embrace of the gender-identity delusion. Psychiatry is particularly prone to confuse political activism with scientific rigor. Such is the case with the new Diagnostic and Statistical Manual of Mental Disorders (DSM-5) and its diagnosis of “Gender Dysphoria,” which emphasizes “incongruence” between one’s “experienced/expressed gender and assigned [that is, birth!] gender.” Incongruence is defined as a subjective feeling. The diagnostic criteria for both children and adults include “strong dislike” for one’s gender on the one hand, and “strong desire” to be otherwise-gendered on the other. The criteria read as though a committee made up of transgender lobbyists, rather than medical scientists, had compiled them. Dissatisfaction with one’s gender and genitals is sufficient to make one a different person. Such magical thinking denies the biological facts of gender—that men and women are different. According to the DSM-5, gender is malleable. Not only does it exist on a continuum between man and woman, but there may also be “some alternative gender.” One needs a dictionary of gender terms to decipher the neologisms that have been created to describe the various stages of transgenderism.

Ironically, this convoluted attempt to deny that “Gender Identity Disorder” (its designation in the ­DSM-4) is a psychiatric disorder is completely unnecessary. There is nothing unique about people who suffer from gender confusion. Their psychopathological vulnerabilities are much like everyone else’s—developmental, neurotic, characterological, and (much less commonly) psychotic. Gender confusion can be a developmental stage in young children who transiently identify with admired or envied characteristics of the opposite sex; it may be a component of the fraught stage of adolescence in which the “identity crisis” is one of self-definition generally; it may represent a “midlife crisis,” in which dissatisfaction with what one has become (or has not become) triggers profound life changes. People can “get stuck” at any one of life’s developmental stages and remain under the influence of its conflicts, in a fixation that psychiatrists have recognized as “neurotic” or as a personality trait or disorder. These terms are not (or should not be) pejorative, as they describe part of the human condition.

We know a great deal about human development. Children achieve gender identity around age three—that is, boys know they are boys and girls know they are girls. And there have always been “sissy” boys and “tomboy” girls, who identify transiently with the opposite sex. Identity, however, is a psychological concept much broader than just gender; it is the defining core of personality. It is an ongoing developmental process, with crucial input in the early years. It shapes our ability to trust both ourselves and others, to achieve autonomy from family, to develop and internalize a value system, to develop mature coping skills, to form intimate relationships, to achieve to the best of our ability. In short, a mature and stable self-image involves knowing oneself and one’s place in the world. Life’s inevitable vicissitudes, at every developmental stage from childhood to old age, can test our self-image and produce self-doubt. Popular delusions such as the transgender craze offer simplistic explanations and solutions for the multidimensional life crises of identity.

It is lamentable that American psychiatry has abrogated its professional role and allowed public hysteria to define the transgender phenomenon. This deprives people of treatment that could lead them to understand themselves and take control of their lives, rather than be passive victims of a one-size-fits-all fad. Children in whom “gender dysphoria” is merely a developmental phase may be subjected to life-altering hormonal treatments, and adults in whom it represents a mid- or late-life crisis may be subjected to sex-reassignment surgery. Transient developmental crises that would be amenable to appropriate psychotherapy are turned into profoundly life-altering, irreversible physical mutilations.

By comparison, anorexia nervosa is a multidimensional disorder, similar to transgenderism in that it involves a profound dissatisfaction with one’s body. However, seriously underweight anorexic patients who see themselves as obese are not treated with weight-reducing liposuction by physicians who go along with their irrational belief. Instead, anorexia is treated as a psychiatric illness. Another body dysmorphia that is currently receiving some notoriety—and acquiring a constituency that would like it to be included in the DSM—is “Body Integrity Identity Disorder” (BIID). Also known as “transableism,” BIID is the desire of an able-bodied person to become disabled—by a limb amputation, or by being blinded, rendered deaf, or even paralyzed. One hopes that common sense, which judges such a desire as grotesque, will prevail over those who would regard it as just another lifestyle choice. The wish to be rid of an offending limb is remarkably similar to the wish of a transgender man to be rid of an unwanted penis.

That purported experts on mental illness should enable the acting-out of a cultural delusion is egregious enough. Most flagrant, however, is their treatment of a mental disorder with mutilating surgery. What can my colleagues be thinking when they prime patients with hormones and prepare them for surgery? Are they themselves delusional, and do they believe that they can change women into men (and vice versa)? Do they think that surgery should be the treatment of choice for people who are dissatisfied with themselves? Have they forgotten, or did they never learn, about psychotherapy, a cornerstone of psychiatry that helps patients understand themselves and their experiences so that they can take control of their lives? Clearly the disaster of a previous attempt to treat mental illness with surgery—prefrontal lobotomy—has not served as a lesson.

Lest common sense fail to convince readers that surgery is not a treatment for a mental disorder, a Swedish study published in 2011 found that over the long term, 324 people who had ­undergone sex-­reassignment surgery demonstrated an alarmingly high suicide rate and experienced considerably higher numbers of ­severe ­psychiatric problems than were present in the general population. Unfortunately, as Charles Mackay has so well illustrated, such scientific evidence is typically ignored in the hysterical contagion of popular delusions. Human nature indeed does not change.  

Richard Corradi is a professor of psychiatry at Case Western Reserve University School of Medicine.