In light of the U.S. v. Skrmetti Supreme Court case, about the Tennessee law that protects children with gender dysphoria from destructive hormone treatments and surgery, it is helpful to consider the actual issues involved.  The transgender debate is not a single issue, but three issues, which to some degree bear on one another but are logically separate questions.

The first issue is the broad logical, philosophical, and biological questions at the root of transgender ideology.  What is a woman?  What is a man?  Can a man become a woman, and a woman become a man?  What is gender?  What is sex?  When is sexual identity fixed, if it is fixed?  What is the relationship between gender and sex?  What is the biological definition of male and female?  Is the human species sexually binary (male or female) or bimorphic (a continuum between male and female)?

These issues are of enormous importance for our culture, and they bear on questions of biology, medical care, and ethics, but they are not the same thing as the issues of medical care and ethics and should not be conflated with them.

The second issue is the effectiveness of transgender medical care.  Do children who are given puberty-blockers really benefit from the treatment?  What are the short-term and long-term risks of puberty-blockers?  What are the effects of cross-sex hormones in patients, especially children?  What effect do cross-sex hormones have on fertility, metabolism, bone strength, cancer risk, and long-term psychological health?  What are the medical and psychosocial consequences of lifelong dependence on powerful mind- and body-altering drugs?  Do castration and the surgical fashioning of fake genitals really make mentally ill children and adults psychologically healthier?

All of these “second issue” questions are straightforward science, unlike the “first issue” questions, which are heavily laden with metaphysics.  The answers to these second-issue scientific questions, as the Cass review has shown, is that there is very little evidence that these treatments actually improve patients’ lives.

The third issue is the ethics of transgender treatments, irrespective of the philosophical and scientific rationale for the treatments.  Is it ethical to destroy normal body parts and functions with drugs and surgery?

Note that this ethics question is distinct from the questions about the logical coherence of transgender ideology and the scientific effectiveness of transgender treatments. Even if transgender ideology made sense (it doesn’t), and even if transgender medical care helped people (it doesn’t), is it ethical to damage a healthy body in service to these goals?

To see more deeply into the question, consider body integrity dysphoria, which is a psychiatric condition related to gender dysphoria.  In body integrity dysphoria, patients believe that a part of their body — a leg, an arm, an eye, etc. — does not genuinely belong to them, and many of these patients ask to have these limbs or organs surgically removed.  It is widely accepted in the medical profession that it is unethical to amputate healthy legs or healthy arms or remove healthy eyes of these mentally ill people.  They need good psychiatric care, not surgical mutilation.  Why is it considered ethical to remove the healthy genitals of mentally ill patients with gender dysphoria when it is not considered ethical to remove the healthy limbs of mentally ill patients with body integrity dysphoria?

It is this ethical question in the transgender debate that really bothers me.  I have practiced neurosurgery for 40 years, and I have cared for tens of thousands of patients, and it is incomprehensible to me that a doctor would give a drug or do an operation with the intent to cause disability — with the intent to destroy a normal body part of a patient.

The prime directive of medical practice is “Do No Harm” — it is the core principle of medical care that I live by and that I teach medical students and young neurosurgeons.  When a patient comes to my office or operating room, my first thought is, “How can I help this person without harming him?”  I would never deliberately damage a mentally ill patient’s normal brain or spinal cord.  I would never cause disability on purpose.

The closest analogue to gender surgery in neurosurgery was frontal lobotomies, performed in the mid-20th century, now understood to be horrendously unethical operations that were intended to disable vulnerable mentally ill patients.  The era of frontal lobotomies was a dark era in the history of neurosurgery.  Gender surgery is basically a sexual lobotomy.

My responsibility as a neurosurgeon is always to restore health, and never to cause disability.  Yet all doctors who practice transgender medical “care” — who prescribe puberty-blockers, cross-sex hormones and surgical removal of breasts and genitals — deliberately cause major disability of one sort or another, such as sterility, osteoporosis, cardiovascular disease, deformity, breast and genital mutilation, and new psychological disturbances among many others.  No other doctors do this.  Transgender procedures are the deliberate infliction of disability and mutilation in order to treat a psychiatric condition, for which psychiatric care, and only psychiatric care, is medically justified.

Irrespective of the ideological and scientific debate about transgenderism, the ethical transgressions of transgender procedures are appalling.  These vulnerable children and adults need high-quality psychiatric care and compassionate social support, not castration with puberty-blockers, cross-sex hormones, and mutilating surgery.  I am ashamed of the medical profession’s embrace of these ghastly treatments, and I call on ethical doctors everywhere to protect vulnerable children and adults from grievous harm caused by the medical profession.

Michael Egnor, M.D. is professor of neurosurgery and pediatrics at Renaissance School of Medicine at Stony Brook University and is program director of the neurosurgery residency training program.

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