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For practical purposes, medicine may be defined as a healing art that aims to relieve suffering caused by illness. Because not all suffering is caused by illness and some illnesses may cause little apparent suffering, it is important for physicians, as practitioners of medicine, to be able to distinguish medical pathology from normal conditions.
Article originally appeared in
Traditionally, signs and symptoms of illnesses could be ascertained through physical examination or, put simply, through what the physician could observe in, hear from, or feel on the patient. Although technical advances in medicine have led to the practice of using various sophisticated diagnostic tests, doctors have continued to make diagnostic determinations that are based first and foremost on history and direct observation of the patient.
In no area of medicine is this principle truer than in psychiatry, a branch of medicine concerned with the treatment of illness that manifests itself in emotional, cognitive, or behavioral disturbance. This is so because, unlike other medical specialties, whose focus of study may be an organ that is susceptible to direct observation or study, the object of psychiatric inquiry is the internal experience of the patient, something that does not lend itself to direct observation. Psychiatrists cannot read minds, but they do listen to what patients say about their thoughts and feelings, and they observe patients' behaviors and emotions.
No less than other specialties psychiatry also relies on a body of knowledge to distinguish a normal internal experience from an abnormal one. To solve any problem, there has to be an understanding of what things look like when the problem is solved, that is, what they are like under normal circumstances. An orthopedic surgeon looking at an open leg fracture has a notion of what a normal, intact leg looks like. Similarly, a psychiatrist examining a paranoid patient has to have an understanding of how his patient's thinking differs from normal thinking. In other words, important to the practice of psychiatry is a commonly accepted notion of what constitutes normal emotion, thought, and behavior.
Psychosis is a term used for a mental state that causes a patient to experience an impaired sense of reality. Psychotic patients see, hear, or otherwise experience reality as other than what it is. For example, a hallucination is a perception of something that is not actually there. Another common manifestation of psychosis is the presence of a delusion, which is defined as "a false belief or wrong judgment held with conviction despite incontrovertible evidence to the contrary."1
If we say that someone is delusional, we have to have a basis for saying why that person's belief does not correspond to reality. For instance, I have a patient who believes that he is the superintendent of the hospital where he is being treated. I know that this patient is delusional because I happen to know the superintendent personally, and he is not the patient. It is also not consistent with the role of the superintendent to be a patient in the very facility that he oversees. Another patient in the hospital believes that inside his head there is an FBI-run computer with the power to stop his thoughts. I know that he is delusional because the object that the patient believes is in his head simply does not exist.
There are other examples in psychiatry in which people's beliefs about themselves are considered pathological. People who claim that they have more than one personality are treated for dissociative (previously called multiple personality) disorder. Underweight patients who believe themselves to be obese carry a diagnosis of body dysmorphic disorder. Similarly, a white person claiming to be black or vice versa for reasons other than personal gain would most certainly be considered delusional.
However, the logic based on which a person's belief about himself is called delusional has been ignored by contemporary psychiatry when it comes to considering people who claim a different sexual identity from the one that their anatomy incontrovertibly demonstrates. According to a statement by the American Psychiatric Association (APA), an organization that considers itself "the voice and conscience of modern psychiatry," "being transgender or gender variant implies no impairment in judgment."2 Hence, according to the APA's logic, a patient in a psychiatric institution who believes himself to be the hospital superintendent, acts (so far as he is able) like a superintendent, and wants to be addressed as such carries a diagnosis of schizophrenia, but a man who believes himself to be a woman, begins to wear make-up and dress like a woman, and consults a surgeon in order to be castrated is considered normal.
The NYC Commission on Human Rights maintains that gender identity is "one's internal deeply held sense of one's gender, which may be the same or different from one's sex assigned at birth.3 This statement intentionally uses language to distort reality. Except in cases of rare medical conditions resulting in ambiguous genitalia, no one's sex is "assigned" at birth any more than the fact of belonging to the human species is assigned at birth.
More significantly, this statement erroneously implies that a person's beliefs about himself carry more legitimacy than the physical facts that contradict such beliefs. Using the Commission's reasoning, can we declare an alternate "age identity" to be legitimately different from one's true age? What about "race identity" or even "species identity"? If one accepts as legitimate the logic by which men may identify themselves as women and insist on being considered as such by others, there is no reason to reject as invalid any number of other idiosyncratic identities that have no basis in reality.
It is unfortunate that the American Psychiatric Association, as the "voice and conscience" of the very medical discipline in a position to point out the delusional nature of such beliefs, has instead chosen to support the transgender agenda and thus lend it an air of medical legitimacy. Whether having a "transgender" or so-called "non-binary" identity causes subjective discomfort is quite beside the point. All experienced psychiatrists have seen patients whose delusions cause them no apparent discomfort. The bigger question is whether one can have a "deeply held belief" so drastically counter to reality as is the belief that one's sex is different from one's anatomy and still be considered normal.
Lacking diagnostic means that produce quantitative evidence of a person's condition, such as blood tests, or unambiguous visual data, such as what one sees on a microscope slide or an MRI image, the field of psychiatry relies on a complex set of mental constructs for its notions of normality and pathology. However, inherent to that set of mental constructs is the notion that there is such a thing as verifiable, objective reality. To suggest that there is no such thing as objective reality, or that reality is less important than what one wishes it were, renders the entire concept of psychiatric disorder invalid. In fact, the only way to accept the transgender phenomenon as psychiatrically normal is to say that, as a measure of reality, physical evidence is subordinate to what a person believes about or wishes for himself. And on that logic, we have no basis for calling anyone delusional.
Right & Wrong Responses
Psychiatric illness has been defined as such on the basis of its causing suffering and disability. Reading through the APA's position on the transgender phenomenon, one gets the impression that the only suffering and disability experienced by "gender nonconforming" individuals stem from prejudice and discrimination on the part of those who disapprove of them. In reality—that is, any reality apart from the current attempt to reframe this phenomenon as a civil rights issue—these individuals do experience a great deal of disability associated with being unable to function adequately in society, as do other patients whose delusions influence their appearance and behavior.
Although the public's reaction to the appearance and behaviors of people who consider themselves transgender may, indeed, be negative, to say that the disability of transgender individuals consists of being the recipients of a negative public reaction means confusing the cause with the effect. The fact is that the disability originates in the abnormal mental experience of "transgender" individuals and not in having been born in the "wrong" body or of living in the "wrong" society. However, according to the inverted logic of those who support the LGBT agenda, when an external reality contradicts the internal experience, the solution lies in altering reality in such a way that it conforms to the internal experience. Hence, the advocated approach to addressing an idiosyncratic internal experience is to give the person a new external reality by means of a surgically altered body and a re-educated society.
Identifying the problem as ultimately external naturally leads to the kind of solutions proposed by the New York Commission on Human Rights: fines and sanctions against individuals and institutions that refuse to recognize the legitimacy of being transgender. Ironically, the fact that the Commission would force others to conform to the beliefs of transgender individuals speaks to just how much functional impairment the latter experience in their everyday lives as a result of their beliefs.
The response of organized medicine, and psychiatry in particular, to the transgender phenomenon has been intellectually dishonest and dangerous to the mental and physical health of affected individuals. The acceptance of transgender beliefs as psychiatrically normal has in many cases led to harmful medical interventions in which individuals undergo so-called "sex-reassignment" surgery. These operations cannot "reassign" sex; they can only disfigure normal anatomy and produce truly monstrous results—mutant human beings with the genotype of one sex and an imitation of the phenotype of another.
That a person would wish to have this done to himself should be grounds enough to suspect mental illness. That a surgeon would perform such a procedure should prompt a criminal investigation. The fact is that, unless we abandon the very notion of normality, we have to judge individuals who experience such discomfort with their sexual anatomy that they are driven to assume the identity of someone of the opposite sex (or no sex) as being psychiatrically abnormal. At the least, the psychiatric community should be working hard to find proper treatment for those with this condition, instead of supporting agendas aimed at forcing everyone else to behave as if this affliction were normal. Lies, even those told in the service of tolerance and diversity, dignify no one—neither those who tell them nor those who believe them. And when psychiatrists begin to validate the delusions of their patients, one begins to wonder if both are not equally ill. •
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