I, too, have an emotional response. But let’s be scientific. If the counselling shows middling success, and the amputation 90%+, why do our feelings, as third parties, overrule the person whose body it is?

Isn’t this true of all treatments? It’s the best we’ve got. It seems to work. It has downsides. We’re looking for better options.

We start with the least invasive option. But we don’t stop midway because something better might one day turn up.

Defining mental illness is imprecise. We’ve gotten it horribly wrong before, from diagnosing intelligent women as hysterics to gay men and women as deviants. We also have a long, failed history of well-meant prohibition.

If we’re seeing preliminary evidence that a surgery makes miserable people happy, I say we follow the lead without prejudice. Maybe we find these peoples’ bodies are picking up on precancerous signs? (Airball.) Probably, we don’t. But my peers’ botox has visibly reduced their faces’ expressiveness; is that mental illness?

Out of all of our emotions, I trust my sense of social disgust least. The world in which it evolved is no more. If I can’t find reason beyond discomfort to question someone’s decisions about themselves, I broadly tend towards letting them be.

(Side note: appreciate the discussion.)

Gender dysphoria - yes, people suffer form it. Transition is the way to lower this suffering. That's the 'cochlear implant' equivalent from your example.

Not OP. But this seems unfair. Not only does the language surround trans persons vary from decade to decade, city to city, it’s also—understandably—guarded.

Someone far from knowing “nothing about the issue,” and moreover, wishes to learn more, could innocuously use language that is offensive in some circles but tolerated—even encouraged—in others.

See for example "sex assigned at birth" https://service-manual.nhs.uk/content/inclusive-content/sex-... as an example from a mainstream medical institution, the British National Health Service.

And transition is not "the cochlear implant", the implant would be "an implant that makes you not dysphoric". Transition is "learning how to live as a deaf person".

This is what repression looks like. Before coming out, while you try to live as you assigned gender - that's living as a deaf person, pretty literally as derealization and depersonalization are kind of 'deafining'. As with deaf kid - you fix the body, not the mind, so with gender dysphoria you fix the body first.

Maybe it's just me, but fixing identities scares me much more than fixing the body. There was studies in which trans people were asked if they would want to be consent with their assigned sex (i.e. trans woman to be happy as a man) - most don't. After transition almost none would agree to change it for 'no dysphoria, assigned sex at birth'. 'Fixing' such people sounds like a very cruel and scary idea.

In some instances we provide a prosthetic that overcomes the defects of the ear, like a traditional hearing aid, or surgery that corrects those defects, and in others we augment the person with a cochlear implant that bypasses the issue with the nerve. We don't yet have the ability to directly modify the brain with surgery or implants for deafness but I'm sure that we would if we could.

It's interesting that we're talking about deafness because there are many instances of deaf people with heredity causes for their deafness opposed to testing their children with new, effective treatments like cochlear implants because they view it as impinging on their deaf culture.

I think that there are many parallels between this and the developing trans culture which will result in trans people being resistant to more effective, less invasive treatments to cure them of their affliction.

Why do certain maladies develop strong identity politics while others don't? There isn't a diabetic identity, or a halitosis community, so why these ones?

Dysphoria goes deeper than just bodily dysmorphia, it's about how you see yourself, not only your body. So changing my mind to make me something I'm not (a man) sounds like a horror - some kind of upgraded lobotomy. That's much more invasive than any surgery. And it's not about culture, it's about understanding that people identities is not a part that you can/should fix.

And speaking about data and science, there is pretty clear evidence that trans people who receive proper care (hormones) and accepted by society live normal happy life as the rest of the people.

That's why people are treated by medical experts for it.

We're merely discussing the best form of treatment.

Yes. And? A stable identity is preferable for the sufferers. Can you explain the problem with that?

I don't see much of an actual solution to these issues in your arguments other than some hand waving about politics as some sort of root cause.

Should taking of legs be the first treatment option? No.

Should people get therapy, medication and other treatment? Yes.

Should those treatments be refined and improved, sufferers of BIID experimented on to improve treatments? Yes.

If society is unable to come up with a treatment that works for years should society deny sufferers this radical treatment forever? No. That is imposing the majority world view on a minority when the difference in world view poses no harm. Yes, society would need to address potential cognito hazards/memes and make sure there are no people doing this for economic incentives or other mental illnesses for which treatments exists.

If society would let people get the treatment, that would not be capitulation. That would be acknowledging that while society has interest in being able to treat that, that interest can not forever outweigh the benefits the radical operation has for the sufferer. Capitulation would be if society stops trying to find a treatment besides radical operation and handed operations out without scrutiny.

It's not sold as the treatment.

And to your comparison to trans folks, top and bottom surgery is not easy to access (and getting harder by the day!). Talk to any trans person and ask them all the things they needed to do and go through to prove to their doctors that they're trans enough. Besides there not being another option, gender affirming surgery works! The patients are largely satisfied with their outcomes! Why do we need to complicate this with suggesting how they should feel or think?

But moreover, who the fuck cares? I had gynocomastea surgery (after years of bodybuilding) and all I had to do was sign a form. Women can elect to get breast augmentation with no evaluation. Why should a trans person have to prove that they deserve a cosmetic surgery that anyone else can get—so long as the outcome is gender conforming? I can get anything I want tattooed on my face today, but someone else can't get their chest flattened for months because...some lab coats don't think they deserve it enough?

Let's run with your idea, if a vast majority of people felt compelled to do these things would society be better off?

The feeling that you're having, is gender dysphoria. That's what trans people feel all the time, every single fucking minute of their lives, every time they look down getting a painful reminder that their body isn't Right; until they fix it - which is a capital-C Cure. Problem solved, forever.

That sounds pretty fucking great to me. Why wouldn't you let people live how they want to?

This would obviously be better than hobbling someone with crutches or a wheel chair and a disability cheque, better for society abd the individual too.

Now what if a doctor decided one day to test this treatment on someone with gender dysphoria and lo and behold it worked just as well for them? The patient suddenly felt great about their body, great about their appearance and they stopped obsessing about changing it with risky and painful surgeries.

This cheap and effective pharmacuticial treatment would instantly become a first line treatment for gender dysphoria, right?

That sounds pretty fucking great to me. Why wouldn't you want people to live their life how they were born to?

What your arguing for in your thought experiment is, effectively, treatment designed to radically change someone's sense of identity without side effects. It's a thought experiment that falls apart once you expand it to other things that were once commonly thought of as mental illness.

To what extent is "sense of identity" innate, and to what extent is it culturally shaped?

For example, "homosexuality" and "heterosexuality" were not something common before the late 19th century. While people still engage in sexual acts with the same and/or opposite sex, such acts did not play a role in their identity.

This is evident as far back as ancient Rome.[0]

> Homosexuality in ancient Rome often differs markedly from the contemporary West. Latin lacks words that would precisely translate "homosexual" and "heterosexual". The primary dichotomy of ancient Roman sexuality was active/dominant/masculine and passive/submissive/feminine.

To the ancient Romans, sexual acts with someone of the same sex wasn't viewed like we do today. They wouldn't have spoken about themselves as "gay" or "straight." Rather, they would have spoken about themselves as "dominant" or "submissive."

This concept runs counter to the way we think about sexual identity today, but it demonstrates that there is far more nurture in the mix than we often like to admit.

And, please note, this is not a judgment on people who identify as homosexual or heterosexual. It is also not a claim that we can "change" someone's orientation. It's simply pointing out that sexual identity is not necessarily something which is purely innate (nature). This is something we tend to take for granted and without much thought in contemporary Western society.

0. https://en.wikipedia.org/wiki/Homosexuality_in_ancient_Rome

This is no different to now, it was only in 2007 that Mahmoud Ahmadinejad claimed there were no gays in Iran. In various nations you can survey the populace and find wildly varying amounts of homosexuality, all correlating closely with LGBT acceptance. Even now I have muslim friends who are gay and openly tell me that they intend on suppressing their desires for their entire life so as to provide a family and not disappoint their parents.

Would your answer to the original question then be that the "sense of identity" is the result of or predominately from nurture? That is, one who sees as "gay" or "straight" sees themselves as such because of culture? Or to put it in a more generic manner, culture determines identity?

Some of the most common observations by our very small trans elderly is that they "found a way to describe" or "finally found the words" for who they are, ie the identity was always there but no terms to identify with.

I think by and large it's nature (fraternal birth order effect, twin studies etc) modulated to the extreme by societal rejection. You dont see gay men in the streets of countries where homosexuality earns the death penalty, you instead see extremely depressed "straight" men :)

People with BIID and Gender dysphoria will kill themselves if they don't receive treatment, and will otherwise ha e poor life outcomes due to the adjacent side effects like depression and self harm that comes.

The only negatives that being bisexual and homosexual have come from external sources as you state.

In other words bisexual and homsexuao people are in a state of homeostasis while people with BIID and Gender dysphoria are not.

And to further play the devils advocate there were plenty of people at the time that believed gay people were a blight on society for multiple reasons. Hence why conversion camps were a thing.

Like if you were born in a society where religious zealots who espoused bisexual bigotry just didnt exist, toxic masculinity wasnt a thing and there was a bunch of bisexual representation in media would you have had that anguish? very unlikely.

People with gender dysphoria face the same negative external influences as you do, arguably worse (lets be real, much much worse) but if it would be removed and they lived in a world without it they would still be discontent with their state, to the point of depression which would result in a poor quality of life and for many suicide.

Thats the hallmark of the disorder. thats what gender dysphoria is.

Lets do another thought experiment, what if we lived in a society where gender reassignment surgery was impossible. like lets ssay we just didnt have the advancements in surgical techniques necessary, but we had much better pharamcuticals. If surgery was impossible, but giving someone a pill like I described in the first thiufht experiment was possible that would be the morally correct thing to do as opposed to doing nothing, right?

Lobotomies were used as a cure for all kinds of different things. If you knew something was a problem and lobotomy was the only thing that seemed to cure it, is it morally correct to do so as opposed to doing nothing? That's why these simplistic thought experiments are bad because there are examples of what happens when you take it to their logical (and often sadly real) conclusion.

Now you understand the reticence towards gender reassignment surgery and why someone would be looking for much lower risk pharmaceutical treatments for gender dysphoria, which is exactly what we ended up doing with brain disorders?

It's worth noting that we still do brain surgery on people, and that we're even moving towards using implants to modulate how the brain functions, as opposed to the crude technique of severing parts their brain with rods jammed into their noses or holes drilled into their heads.

I have a feeling that we'll look back on this time when we cut off penises and inverted them into crude vagina like canals, jammed silicon bags full of salt water into chests and pumped people full of hormones as barbaric as the lobotomy era.

They're things that we do out of convenience because they're the best that we have, not because it's what we want to do.

I'm pretty sure this is 100% false. If in doubt, ask your local Catholic priest about it.

People have an inherent, fundamental Right to their own body, to mold it into the image that they choose. If they want to take your magic pill? They have every Right to, good on 'em. But if they want their body to be a certain way, they have that Right too.

Right now the NHS is dealing with a "Why didn't anyone stop me? All I got was positive support!" situation from someone who is detransing.

Try this experiment on yourself and think that there is a treatment to make you think you are woman/man. How's it make you feel? And together with that, reflect on what exactly make you be a man/woman - your body or your psyche.

There is a lot parallels between gender dysphoria and BIID, but GD is bit more than just 'this is not my body'.

I can highly recommend to give the conclusion section a read. I think the authors are well aware of these issues, to the point that this scoping (no other treatment available right now / other options exhausted + person needs help right now) makes me slightly supportive.