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A Thought Experiment on Gender-Affirming Care

What if such medical treatments either were impossible or perfect?

Copyright © 2024 by Ari Armstrong
March 26, 2024

The following comments contain some spoilers for episodes of the science fiction show The Orville, which I highly recommend, specifically "About a Girl" in Season 1 and "A Tale of Two Topas" in Season 3. A third episode, "Midnight Blue" in Season 3, completes the "Topa Trilogy."

In The Orville, Topa is a child born female to two Moclan parents. On Moclus, almost all children are born male. Moclan society is extremely masculine and strongly biased against women, and almost all romantic couplings are homosexual. Officially, women do not exist in Moclan society, which means, in practice, that they are driven underground. In rare cases of a female birth, the Moclan government requires that the infant undergo gender reassignment surgery to make them male. Indeed, we come to learn, one of Topa's parents was born female and underwent such gender reassignment surgery in infancy.

Because one of Topa's parents, Bortus, serves aboard The Orville as an officer of the Planetary Union, the question comes up as to whether the Union should allow the gender reassignment surgery. Tensions deepen when Bortus, influenced by his human friends, comes to oppose the procedure. A Moclan court rules that the gender-reassignment surgery must proceed, and the Union capitulates. Topa is changed surgically from a female to a male.

Later, though, Topa experiences what we would call gender dysphoria. When Topa learns that she was born female, she decides to surgically transition back to female, and that is the outcome.

On one level, the story is about someone born their "true" gender, altered physically such that physical characteristics no longer match gender as (eventually) manifest mentally and emotionally, and then altered back such that physical characteristics again match mental and emotional gender. On that level, the story can be taken as a critique of forcing someone to change their gender.

On another level, if we abstract away from the particulars of Topa's circumstances, the story recognizes a distinction between the physical characteristics of gender and the mental and emotional characteristics of gender, and so can be taken straightforwardly as supportive of gender-affirming medical care. We can imagine an alternate story in which Topa is born male, then later experiences gender dysphoria and seeks gender-affirming surgery to become female. According to the premises of the show, that would be fine.

The show agrees with me that gender is not purely a "social construct," that (often) there are real mental and emotional manifestations of gender that usually (but not always!) correspond to genitalia. In other words, it's "like" something to be a woman or to be a man, mentally and emotionally, although of course experiences can vary from person to person. Although "mental gender" and "physical gender" (as we might call them) usually align, sometimes they do not. When they do not align, a person may choose to be transgender. And, in my book, that's totally fine.

Here is where I want to suggest a thought experiment. In The Orville, medical care is far advanced relative to our modern-day medicine. The surgery that Topa undergoes as an infant completely transforms her, at the physical level, into a male. Not even Topa can tell the difference, physically. It takes a doctor with special scanning equipment to be able to find signs of the procedure. Likewise, when a doctor surgically transitions Topa back to female, the operation goes perfectly. Topa is again, at the physical level, a functional female in every respect. No one, except for a doctor with special scanning equipment, would be able to tell that Topa had ever received gender reassignment surgery.

Now consider a world in which medical care is much worse than what we have today, in which doctors perform only the simplest of surgeries and there are no hormonal treatments. In that world, gender-affirming medical care simply does not exist. If Topa had been born as a female in that world, given the strong Moclan bias against women, she would have been killed, her parents would have had to take her underground or off-planet, or her parents would have had to raise her as a boy, hoping that she was never found out (that seems unlikely). And, if Topa had been born as a male into that world, Topa never could have sought gender-affirming care (such does not exist in this scenario), no matter the severity of Topa's gender dysphoria or the strength of Topa's desire to live as a woman.

We can imagine the quality of gender-affirming care on a continuum, ranging from totally non-existent to practically perfect.

Now consider our world, in which medical care is somewhat advanced but not nearly as advanced as it is in the world of The Orville. In our world, hormonal treatments of children can have, or at least various people plausibly claim they can have, pretty severe downstream effects, including infertility and brittle bones. Although doctors can turn a penis into a vagina and vice versa, the procedure is not pleasant, and the results are not perfect. A surgically formed penis or vagina just is not going to function the way that a typical "natural" penis or vagina functions. (This probably helps explain why most transgender people do not get "bottom" surgery on their penis or vagina.)

So, the question is, how do we think about gender-affirming care, given the quality of current medical technologies?

Obviously, even if gender-affirming care were at the level that it is in The Orville, religious conservatives still would be against gender-affirming care. Fundamentally, they oppose gender-affirming care not because they question the quality of that care. They complain about the quality of the care merely as a pretext because they oppose gender-affirming care as such. We should suspect, then, that they tend to exaggerate the problems with gender-affirming care, because they would oppose gender-affirming care regardless of its quality.

What I think is that current problems with gender-affirming care should and generally do make a person think long and hard before seeking it. I think that adults have a basic right to seek such care. I think that children starting at puberty probably usually have the capacity to rationally consent to such care. But I do worry about the potential for downstream physical problems, and I worry that in at least some cases a person might want to reverse the treatment but be unable fully to do so.

Certainly an infant is incapable of consenting to surgery, so adults should subject infants only to medically necessary surgery. Obviously what was done to Topa as an infant was horrible. But then, I also oppose routine circumcision of the male penis. I find it astonishing that the same religious conservatives who are perfectly enthusiastic about cutting off the foreskins of infants' penises oppose letting people capable of rational consent get gender-affirming care. The difference between Topa as an infant and Topa as a juvenile is that older Topa is capable of making her own decisions.

I also think that someone should feel free to live as a transgender person without getting gender-affirming medical treatments, and that the rest of us should welcome such people and treat them with respect and dignity. I worry that some people seek gender-affirming care largely to avoid the sort of discrimination and mistreatment that they otherwise would face. Many transgender people face discrimination and mistreatment in any case, but perhaps some transgender people think that getting gender-affirming medical care can reduce such mistreatment.

So long as gender-affirming medical care remains suboptimal (as it probably will remain for a long time), and even if it is perfected, I would like transgender people to feel perfectly comfortable and welcomed in our society whether or not they seek gender-affirming medical care.

It seems to me that it has become too widely accepted and expected that a transgender person must seek gender-affirming medical treatments. Transgender people should feel free to seek gender-affirming care, and they should feel free not to. It's perfectly fine for a transgender woman to have well-defined muscles, chest hair, and a penis. And it's perfectly fine for a transgender man to have well-formed breasts and a vagina. I worry that "we" have not created enough cultural space for such possibilities.

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