TRANS & ETHICS. (1) Dr. Marci Bowers, WPATH, the transgender debate, and the ethic of autonomy
How should the Western ethical tradition evaluate the controversies over 'affirmative care' for transgender minors?
All over the West, thousands of minors are asking for sex-change surgeries.
WPATH and other advocates of affirmative care favor such surgeries as compassionate support for the full expression of these minors’ gender identity.
Detractors consider that most of these minors suffer from a temporary mental affliction, and hence that sex-change surgeries are a net harm.
This is a major ethical controversy. Who is right?
What is right? What is wrong? What is good? What is evil?
Westerners, ever more polarized, are grappling with these questions anew in a wrenching—and sometimes violent—pivot in our civilizational development. As a Westerner, I regret all this fear and loathing that now benights us. But as a cognitive and political anthropologist I take a professional interest.
The remarkable debates over the social and legal implications of transgenderism are a goldmine of data for CAD researchers at the intersection of anthropology and psychology because both sides in the transgender debates argue their case in moral terms, and CAD researchers have given us the most useful taxonomy of moral judgments.
This taxonomy—originally proposed by Richard Shweder and recently developed by Jonathan Haidt and colleagues—identifies three major ethics or modes of moral reasoning that humans commonly employ: community, autonomy, and divinity (CAD). Depending on which ethic is dominant in a particular time and place, or for thinking about a particular domain, people ask a different question (whether explicitly or implicitly) to decide if something is moral:
Ethic of community: Does this make the community—the legitimate unit for desirable outcomes such as stability and prosperity—better off?
Ethic of autonomy: Does this cause an individual—the proper focus of rights, obligations, and liberties—harm?
Ethic of divinity: Is our ‘spirit’—whether located in our bodies, our communities, or our symbolic expressions—polluted/desecrated or elevated/sanctified by this?
As a result of our Judeo-Christian heritage (“love your neighbor as yourself”—Leviticus 19.18) and its increasingly secular efflorescence since the European Enlightenment, the ethic of autonomy is strongly dominant—especially in formal and institutional settings—in Western, Educated, Industrialized, and Rich Democracies, or WEIRD societies, as Joe Henrich has taught us to call them.
I have elsewhere described WEIRD morality more fully and recommended that Westerners stick to it. But I won’t belabor that recommendation here because both sides in the transgender debates claim to be working to reduce harm to individuals. In other words, everyone in the transgender controversies accepts ‘We have reduced harm to the individual’ as the central meaning or one-sentence goal organizing the discursive grammar that governs the Western ‘game’ of ethical disputation.
Hence, since we are not fighting over the rules, I can move directly to investigate which side is making the soundest harm-reduction claims.
The thorniest question: care for transgender minors
Up until a few years ago, only a small handful of cases had been recorded of children and adolescents expressing a profound dissatisfaction with their own bodies and wishing to appear to the world, and to be socially treated as, members of the opposite sex. But in recent years we have seen a massive rise in such cases: thousands upon thousands all over the West. I will consider in a future piece the two main hypotheses proposed to explain this sudden rise. But my quarry here is the question of how to care for these minors.
This is, without a doubt, the thorniest ethical issue in the transgender debates.
Under the care regimen that, until recently, was institutionally supported, it was believed that such minors had a psychological affliction—called gender identity disorder—that therapy and/or the simple passage of time would help extinguish. Hence, irreversible changes, and in particular sexual reassignment surgery, it was thought, should wait until one could observe that, following puberty and adolescence, the desire to change sex had not been extinguished. This policy was called watchful waiting.
In the new standard, called affirmative care, the term gender identity disorder—and any suggestion that it’s a mental affliction—have been dropped. The fifth iteration (published 2013) of the Diagnostic and Statistical Manual (DSM V)—the authoritative ‘Bible’ of American psychiatry—now speaks instead of gender dysphoria, which is a diagnosis of sorts but does not imply a mental disorder (dysphoria means “a state of feeling very unhappy, uneasy, or dissatisfied”).
This increasingly dominant view, expressed officially by our most powerful institutions, asserts that minors who say they are ‘trapped in the wrong body’ should be considered a case of gender nonconformity, and, according to the APA (American Psychological Association), “gender nonconformity is not in itself a mental disorder.” In 2017, Denmark became “the first country to remove trans people’s classification as ‘mentally ill.’ ” Others have followed suit.
Proponents of affirmative care say they mean to avoid stigma for transgender minors—as they are now called—and to validate their mental experience. In practice, this means accepting their gender presentation, adopting the pronouns they prefer, socially supporting any expressed desire to transform their bodies with puberty blockers, hormone therapies, and cosmetic surgeries, and making such transformations legally, institutionally, and even economically available to them.
Many physicians, psychiatrists, therapists, educators, and politicians—dominant today in our institutions—have presented affirmative care as the vanguard of compassion and enlightened intervention for transgender minors. They have argued, in the strongest terms, that their approach is a moral victory in the battle to protect minorities from prejudice and to ensure tolerance for the full expression of all identities: the latest stage of emancipation for discriminated and oppressed minorities in the West. According to them, by following such policies we protect transgender minors from the psychological harm that social denial of their true identities would otherwise impose. Unless we do this, they say, we will lose many people to suicide.
The strong moral stance described above increases the probability that detractors of affirmative care will be discursively represented as transphobic: mean-spirited racists who reject trans-identifying individuals as such. But while transphobes no doubt exist, opposition to affirmative care hardly requires transphobia. Many—I dare say most—opponents of affirmative care for minors do so out of concern for the health and happiness of those very same trans kids whom affirmative-care proponents claim to be emancipating.
These detractors argue that the brains and bodies of minors are still in development and hence that no ‘true identity’ has definitively stabilized until after puberty and adolescence. Watchful waiting, they claim, was always the right policy.
Given that children inhabit a variety of invented roles in a world of the imagination, and that adults reasonably and routinely interpret all that as ‘play,’ we must question, say detractors, whether it is compassionate and wise to suspend this interpretation for purposes of supporting a new social identity and irreversible changes in their bodies.
And given that adolescents are subject to all sorts of media and peer influences, do poorly at evaluating risk, and lack the best judgment, they ask: Don’t we, as adults, have a responsibility to protect them from decisions they may later reject and regret? Isn’t that why we restrict some of their rights (for example, to smoke, drink, drive, vote, engage in pornography, have sex with adults, etc.) until they are of age? Can minors whom we cannot trust with a pint of beer meaningfully consent to surgically—and irreversibly—transform their sexual organs?
According to these detractors, the overwhelming majority of minors who express a trans identity will later desist; any transformations to their bodies will therefore later be perceived as harm. Hence, suicide, in their view, is more likely for those who undergo sexual transition as minors than for those who don’t. But even without suicide, insist the detractors, unhappiness will be the most common long-term outcome of a sexual transition. Some have even characterized the consequences of affirmative care as a “medical atrocity.”
I’ll consider both sides of this—obviously heated—controversy. But it makes sense to examine first the institutionally dominant contingent: proponents of affirmative care. We’ll see later (in my next piece) how the critics respond from the sidelines.
The world-renowned gender-affirming care expert: Dr. Marci Bowers
Dr. Marci Bowers, M.D., gynecologist and surgeon, is president of the World Professional Association for Transgender Health (WPATH), an international group that sets guidelines around the world for transgender care and which has strongly recommended that medical and other institutions making contact with minors adopt affirmative care policies.
Dr. Bowers’ website informs me that she is “the first woman worldwide to hold a personal transgender history while performing transgender surgery.” And here I must pause, because an evolving etiquette increasingly demands that we be respectful of the specific—and sometimes highly idiosyncratic—manner in which various identities wish to be referenced. And so, by way of complying with Dr. Bowers’ wishes not to be called a transgender woman, allow me to explain her use of the phrase “personal transgender history,” which is a bit unusual.
‘Trans woman’ or ‘transgender woman’ are terms commonly employed for biological males who transition. But some people in this category, including Bowers, now reject the adjective because they consider themselves women, period. The phrase “personal transgender history” is how Bowers references her sexual transition without putting adjectives on her fully claimed womanhood. This explains why in the film What is a Woman? (premiered in 2022 and recently distributed by Twitter) she corrected Matt Walsh—a conservative podcaster opposed to sexual transitions—when Walsh suggested that she was a transgender woman:
Walsh: Dr. Marci Bowers, first of all, thank you for talking to us.
Bowers: My pleasure!
Walsh: So, you are a world-renowned gynecologist and surgeon. And you are also a transgender woman. Can you tell me a little bit about…—
Bowers: No. I mean, I… I identify as a woman. But…—
Walsh: You are a woman, right.
Bowers: I’m a woman with… I mean, that’s my life, day to day [being a woman]. But I have a transgender history.
This way of speaking that Bowers prefers—itself a point of dispute in the transgender debates—has become increasingly influential, at least in formal settings and documents where language follows the official recommendations of major institutions and government bureaucracies.
Wikipedia, for example, whose guidelines express profound respect for mainstream and official sources, would describe Bowers as “a woman who was assigned male at birth.” This, notice, does two things: 1) it confers the status of an ontological prior to a choice that Bowers made in late-adolescence to identify as a woman; and 2) it reduces the biological fact of her maleness to someone else’s ‘choice’ when she was “assigned male at birth.” Others insist that a simple description of the historical and biological facts—one that, moreover, avoids labeling, value judgments, ideological posturing, and a confrontation with reality—is that Dr. Marci Bowers is a male who underwent cosmetic surgery to appear female and who identifies as a woman.
Dr. Marci Bowers is celebrated as a pioneer in the field of Genital Reassignment Surgery and is commonly cited as the top surgeon in the sexual reassignment field. She has been called the US’s “most popular gender-reassignment surgeon.” Her work, and that of her mentor, Dr. Stanley Biber, whose practice she took over, is so important that Trinidad, Colorado, the town in which she is based, is now known as “The Sex Change Capital of the World.” But her influence extends far beyond that town, as another article explains: “[Bowers] has started programs at Sheba Medical Center in Tel Aviv, Israel, Mount Sinai in New York City, Denver Health in Colorado, and Women’s College Hospital in Toronto, Canada.”
Bowers’ identity and life experience, professional status, cultural impact, and institutional position heading WPATH, the international standard setter for transgender care, combine to make her a powerful authority for those arguing in favor of gender-reassignment surgeries for minors. As a massive influence in her field, she is the go-to person for anyone wishing to understand what affirmative-care proponents are saying. Accordingly,
“[Bowers] has spoken about her practice and other transgender topics in several documentaries, interviews, news reports, and articles. Media appearances have included The Oprah Winfrey Show (2007), The Tyra Banks Show (5 episodes), The Today Show, Matt Walsh’s What is a Woman?, and CBS Sunday Morning feature. She is also the featured surgeon in the six-part 2006-2007 television series Sex Change Hospital. In May 2020, The Times featured Bowers on their Science Power List.”
Moreover, as explained on her own website,
“[Bowers] was interviewed in 2021 by Leslie Stahl for the CBS News program 60 Minutes. Dr. Bowers is recognized as one of the 100 most influential LGBT people on the Guardian’s World Pride Power List and one of Huffington Post’s 50 Transgender Icons, was called the Transgender Surgery Rock Star (Denver Post), the Georgia O’Keefe of Genitalia (unknown), and the Beyonce of Bottom Surgery (KPFK-FM North Hollywood).”
All of this is to make clear that I have gone straight to the most relevant and authoritative source for facts and arguments from the affirmative-care side.
According to Dr. Marci Bowers, what is the rate of regret for sex-change surgeries?
On the subject of her work, Bowers explained the following to Matt Walsh in the documentary film What is a Woman?:
Bowers: A vaginoplasty is the creation of a female vagina and vulva. We are altering the physical characteristics of the individual to fit better with a gender identity that is female.
Walsh: This is all constructed from the penis?
Bowers: Yes, that’s right. The surgeries are quite refined in the sense that they really…, not only do they look like female anatomy but they also function that way—for the most part. I mean, it’s a bit of a Faustian bargain, you know. It’s not perfect.
Walsh: Does anyone ever regret their surgeries, or…? Well, we know they do, but how often do people regret their surgery?
Bowers: Well, actually, we don’t know that they do. There are legitimate de-transitioners, and there are people who truly feel that in their journey they may have made a mistake. Now, fortunately this is a really, really UNcommon phenomenon.
(The especially strong emphasis in the last phrase, which I have done my best to convey with text, belongs entirely to Bowers.)
It is unclear above whether Walsh and Bowers are talking about the rate of regret for transitioners generally or for those who got their sex-change surgeries as minors. But when Reuters, also in 2022, specifically inquired about minors, Bowers did speak directly to this:
“ ‘These patients are not returning in droves’ to detransition … Patients with regret ‘are very rare,’ she told Reuters. ‘Highest you’ll find is 1% or 1.5% of any kind of regret.’ ”
Naturally, this is the key claim for proponents of sexual transitions for minors.
As discussed above, the ethic of autonomy is the Western discursive grammar on matters of ethics, and the ethic of autonomy is focused on harm. The one-sentence goal of this grammar is: ‘We have reduced harm to individuals.’ Since one must always be grammatically correct, one may not recommend sexual reassignment surgeries for minors unless one is also claiming that, for individuals expressing a trans identity, such surgeries produce lots of benefits and almost no harm, as would be reflected, of course, in a low rate of regret. And as we see above, proponents do claim this.
And they double down. Because, according to them, what causes harm is discussing cases of regret. As Reuters explains:
“Doctors and many transgender people say that focusing on isolated cases of detransitioning and regret endangers hard-won gains for broader recognition of transgender identity and a rapid increase in the availability of gender care that has helped thousands of minors. They argue that as youth gender care has become highly politicized in the United States and other countries, opponents of that care are able to weaponize rare cases of detransition in their efforts to limit or end it altogether, even though major medical groups deem it safe and potentially life-saving.”
Those awed by institutional authority may consider that the entire question of gender-affirming care—which includes puberty blockers, hormone treatments, and sex-change surgeries for minors—has been settled if “major medical groups deem it safe and potentially life-saving.” But, historically, institutional authorities have been known to make serious mistakes and even to commit horrific crimes.
For example, during the heyday of eugenics, in the first half of the 20th century, “major medical groups” in the West were instrumental in falsely diagnosing lots of people as ‘genetically feebleminded,’ and these diagnoses were used by State authorities to deny them basic human rights and their civil, political, and reproductive freedoms. Hundreds of thousands of people were incarcerated or forcibly sterilized in the United States. This was later taken to even greater extremes in Nazi Germany.
So we must be careful.
As responsible, democratic citizens who will not be stepped on or condescended to by any kind of authority, we must ask: Exactly how did these “major medical groups” establish that sexual reassignment for minors is “safe and potentially life-saving”?
Or put it this way:
Have careful scientific studies established the rate of regret for sex-changes in minors?
A priori, one is inclined to guess ‘yes,’ because sexual reassignment surgery is a dramatic intervention and doctors have an ethical responsibility—ritually expressed in their binding professional oath—to ‘First, Do No Harm…’ So the question of potential harm, one imagines, must have been investigated with indirect evidence, or else on a few ethically justifiable test cases, before performing these life-altering surgeries on thousands of minors. One also expects that, having performed thousands of these surgeries, a strong interest in the rate of regret would have produced already a multitude of studies.
Moreover, Bowers, the world expert, gives a rather exact figure for harm: “Highest you’ll find is 1% or 1.5% of any kind of regret.” This way of speaking, “highest you’ll find,” plus her precision, conjure in my mind a picture of Bowers diving into a prolific academic literature and looking in it for the “highest” scientifically established figures “of any kind of regret,” only to “find”—to her relief—nothing higher than 1.5%.
So I expected Reuters to tell me that, after consulting legions of extant studies on this question, their fact checkers had found Bowers’ figure closely in agreement with abundant and high-quality scientific evidence. But Reuters reported the opposite.
“The incidence of regret could be as low as clinicians like Bowers say, or it could be much higher. But as Reuters found, hard evidence on long-term outcomes for the rising numbers of people who received gender treatment [puberty blockers, hormone treatments, and sex-changes] as minors is very weak.”
I went to verify this myself and found that Reuters was telling the truth.
To wit, also in the year 2022, when the UK newspaper The Telegraph spoke to John Arcelus, “a doctor at the NHS’s [National Health Service’s] Nottingham Centre for Transgender Health,” they learned that “there are … no clinical cohort studies of those who regret their decision and ‘detransition’ after receiving ‘irreversible’ treatment.” (‘Irreversible treatment,’ when speaking of interventions on transgender minors, is a euphemism for sex-change surgeries.)
And guess who agrees with Dr. Arcelus? Dr. Marci Bowers.
I found this to my shock when consulting a paper co-authored by Marci Bowers and titled ‘Standards of Care for the Health of Transgender and Gender Diverse People, Version 8,’ published in the International Journal of Transgender Health (also in the year 2022). That paper states the following:
“At present, no clinical cohort studies have reported on profiles of adolescents who regret their initial decision or detransition after irreversible affirming treatment.”
So, at least when she is writing peer-reviewed papers, Bowers concedes what Reuters claims: for the most part, rigorous data do not yet exist on the rate of regret for sexual reassignment surgeries in minors.
Where some data do exist—just a trickle—is on the question of regret for puberty suppression. Drugs such as Lupron, originally used for ‘chemical castration’ (for example, of sex offenders), have recently been adopted as therapy—from the onset of puberty—for children who consider themselves transgender. The idea is to suppress the natural hormone-driven changes at this stage of development and thus ‘pause’ the expression of secondary sexual characteristics for those who may soon want a sex-change operation. The paper mentioned above, co-authored by Marci Bowers, shares that two Dutch studies found rates of regret for puberty suppression as high as 3.5%.
This is already more than twice what Bowers claimed to Reuters was the absolute “highest” rate of regret for reassignment surgeries. And that is significant, because puberty suppression is less radical, as an intervention, than reassignment surgery, and it is partially reversible. So it is hardly outrageous to suggest, from this evidence, that regret for irreversible sex-change surgeries will probably be higher than 3.5%. But how much higher we just don’t know—the data do not exist.
All of which begs the question: Why did Marci Bowers give Reuters such a precise—yet entirely unfounded—number, 1.5%, for the rate of regret in reassignment surgeries for minors?
A conflict of interest
Once formulated, this question draws my attention to a troubling observation.
When institutionally powerful experts who determine guidelines for transgender care, such as Marci Bowers, tell the media—without any data but with plenty of emphasis—that regret for transition is a “really, really, UNcommon phenomenon,” and they cite precise figures such as 1.5%, transgender minors and their parents who are seeking guidance and who, like most people, are awed by institutional authority, will feel confident that the benefits of these surgeries far outweigh the harms. The effect will be to swell demand for these surgeries. And that, in turn, will make lots of money for Marci Bowers.
How much money?
An article about Bowers explains that her patients “can spend up to $100,000 on total transition costs.” That ain’t pennies. Bowers has become the rainmaker at her hospital: “she brings about $1.6 million per year to the hospital, performing an estimated 130 surgeries per year.” The town of Trinidad, Colorado, which Bowers’ practice has turned into “The Sex Change Capital of the World” (a moniker that town authorities have embraced), has also felt her economic impact. Tom Davis, administrative assistant for Trinidad’s Chamber of Commerce, has put it like this: “ ‘If Dr. Bowers were to leave, it would affect certain aspects of the town … The hotels would take a major cut, and the hospital would take a major hit.’ ”
Marci Bowers is a money-making juggernaut.
Making so much money from sexual reassignment surgeries in minors puts Marci Bowers at the center of a massive conflict of interest. Why? Because Bowers is president of the World Professional Association for Transgender Health (WPATH), and as such she has contributed powerfully to make affirmative care, the world over, the professional standard of care—the very standard of care that promotes the sex-change surgeries so terribly lucrative for Dr. Marci Bowers.
In September 2022, The Telegraph reported that, in the new WPATH guidelines, “minimum ages for puberty blockers and surgical interventions for young people who think they are transgender have been removed.” WPATH was now recommending that children expressing a trans identity might begin with puberty blockers and hormone therapies as early as nine, and, after twelve months of that, get a sex-change surgery.
Marci Bowers’ responsibility for this cannot be minimized. These new guidelines were all developed under her tenure, with her authority. She was interim president of WPATH from November 2020 to March 2021, substituting for Walter Pierre Bouman (with his full support) while he underwent and recovered from heart surgery, and then she became the WPATH president for the period 2022-2024.
It is Dr. Marci Bowers who’s been pushing for ever younger minors to get puberty blockers and sex-change surgeries even though—I remind you—we still don’t know what the rate of regret is. (And this push to lower the age threshold came despite Marci Bowers’ admission, also from 2022, that puberty blockers for children ages 9-11 eliminate the possibility of experiencing orgasm.)
Now, think back to why we want something like the FDA (Food and Drug Administration of the United States), and not the pharmaceutical companies, evaluating the safety of pills: because pharma companies make more money if the risks of their pills are never properly investigated and publicized, so you don’t want pharmaceutical companies to be judge and jury on the question of possible harms. But having an FDA, of course, is of meager benefit if Big Pharma has achieved regulatory capture of this agency, meaning that they somehow control the FDA. In such a case we can expect that the FDA will lower its standards to benefit its true masters, and that more people will be consuming more dangerous products.
Strictly speaking, WPATH is not a case of regulatory capture because, as the New York Times explains, “[their] guidelines are not binding.” But the structure is nevertheless similar because, as the NYT also explains, WPATH guidelines do in practice “provide a standard for doctors across the world.” Here is one prominent example: in the United Kingdom, says The Telegraph, “the standards of care from The World Professional Association for Transgender Health (WPATH) … have underpinned NHS [National Health Service] guidance.” The Clinical Advisory Network on Sex and Gender (CAN-SG) explains that, in addition, “the materials produced by WPATH … are cited in legal cases. … [and have] influenced … guidance produced by the Royal College of Psychiatrists.”
We don’t have much data yet. But we do need it. Because, with the fox—as they say—guarding the henhouse, it is hardly outrageous to ask whether sexual reassignment surgery might not be doing a whale of harm to our minors.
Now let’s apply the ethic of autonomy
The foundational standard in the moral grammar of WEIRD civilization, the ethic of autonomy, has at its center questions of harm (Jonathan Haidt often says “harm and fairness,” but many—perhaps all—cases unfairness may be interpreted as a form of harm.) So, in the West, ever since the Enlightenment, we tend to reduce ethical discussions concerning new policies to the following question: Does this cause a net harm (and how much of it, relative to other options) to individuals?
This is why the Hippocratic Oath, which all Western doctors must solemnly swear, starts with: ‘First, Do No Harm.’ And that principle—‘First, Do No Harm’—underlies the Nuremberg Code, elaborated after the medical atrocities of the Nazis to protect the human rights of patients from the overreach of unethical doctors.
One translation of ‘First, Do No Harm’ goes like this: Do not surgically remove the reproductive organs of an adolescent or child to substitute with modified tissue that simulates a sex change before finding out whether this radical intervention imposes a net harm.
Yet this is what happened: without first investigating the possible harms, “major medical groups” have already vouched for the safety of sexual reassignment surgery in minors: they tell us they “deem it safe and potentially life-saving” even though no rigorous data yet exist on the rate of regret. And they have rushed to make themselves wealthy performing these surgeries on thousands upon thousands of minors, moreover pushing to do them on ever younger children.
This is already so far away from anything that I can remotely consider ethical behavior that my negative judgment on these medical doctors will not be altered even if it should turn out, entirely by luck, that sexual reassignment surgery is of tremendous benefit to transgender minors.
But I doubt, in any case, that we will be so lucky. In my next piece, I will investigate further the question of possible harm, and I will consider the arguments of detractors who are looking at the scant evidence (most of it indirect) that can be brought to bear on this question.
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